Your Name

Your Phone

Your Email

Best Way To Contact You
 Phone Email Either

Best Time To Contact You
 Morning Afternoon Evening Anytime Weekday Weekend

Are You The Home Owner?
 Yes No

Are You Interested In Selling The Property?
 Selling Keeping

Have You Received any notices from your Lender, Court, or from an Attorney, either Hand Delivered, or In The Mail?
 Yes - Hand Delivered Yes - Mail No

Property Address

City and State

Zip Code

Type Of Property
 Single Family Condo or Townhome Duplex Multi-Family Commercial

Property Details
 1 Bedroom Two Bedroom Three Bedroom Four Bedroom Five Bedroom 1 Bath Two Bath Two and Half Bath Three Bath

Square Footage of House

How Many Months Are You Behind On Payments?

Have You Filed Bankruptcy?
 Yes No Thought About It

If You Answered Yes Above, Please Enter Year
 2002 2003 2004 2005 2006 2007 2008 2009 2010

Are You Currently Employed?
 yes no laid-off disabled retired

Primary Lender And Loan Balance

*HELOC Or Second Note On Property
 yes no

Name Of Second Lender And Loan Balance (if any)

Are There Any Other Liens On The Property? If So, Please List The Name Of The Lien Holder(s) and Approximate Balance of Lien

Is Your Home Currently Listed With An Agent?
 yes no

How Did You Find Out About Us

Anything Else You Believe We Should Know?