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Requester's Information
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| Name: |
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| Company: |
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| Phone: |
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| Fax: |
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| E-mail: |
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| Borrower Information |
| First Name: |
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| Last Name: |
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| Address Street 1: |
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| Address Street 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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| Co-Borrower Information |
| First Name: |
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| Last Name: |
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| Contact Information |
| Daytime Phone: |
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| Evening Phone: |
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| Email: |
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| Financial Information |
| Loan Type: |
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| Loan Amount: |
(USD) |
| Property Information |
| Address Line 1: |
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| Address Line 2: |
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| City/Town: |
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| Zip Code: |
(5 digits) |
| State: |
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| Property Type: |
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| Occupancy: |
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| Purchase Price: |
(USD) |
| Appraised Value: |
(USD) |
| Mortgage Balance: |
(USD if applicable) |
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Purchase Information
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| Title Preference: |
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| Attorney Name (if not Maine Title Services): |
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| Attorney's Address: |
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| City/Town: |
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| Zip Code: |
(5 digits) |
| State: |
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| Attorney's Phone #: |
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| Insurance Agency (Homeowner's): |
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| Agency's Phone #: |
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Refinance Information
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| Current First Mortgage Lender: |
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| Loan/Account #: |
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| First Lender's Phone#: |
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Current Equity/Second
Mortgage Lender: |
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| Loan/Account #: |
|
| Second Lender's Phone #: |
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| Other Information |
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