Purchaser name(s):______________________________________________

Seller Name(s):__________________________________________________

Property address:________________________________________________

Social Security # Name:___________________ SS#_____________________
                            
                                Name:___________________ SS#_____________________

Home phone: ____________________  ____________________________

Work phone:  ____________________  ____________________________

Cell phone:    _____________________  ____________________________

Purchaser's marital status: (__) Husband & Wife (__) Single (__) Married

Taking title to new home as:
(__) Sole Owner
(__) Tenants by the Entirety (can only be taken if you are husband & wife)
(__) Joint Tenants with the right of survivorship (for two or more purchasers)
(__) Tenants in Common (two or more purchasers with NO right of survivorship)

Is a Power of Attorney needed at closing? (__) Yes (__) No
If so, who is the party granting P.O.A. ______________________________
Who will hold the P.O.A. _________________________________________

Lender Information:
Lender name: ____________________________________________________

Loan Officer: _____________________________________________________

Phone Number: ____________________ Fax Number: ____________________

Is there going to be more than one loan? (__) Yes (__) No

Homeowner/Hazard Insurance Information:                                  
Name of the Insurance Company_____________________________________
Agent Name:_____________________________________________________
Phone Number:___________________________________________________
Annual premium amount:___________________________________________

Any other information such as seller paid closing cost credits note here:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________