Requester's Information
Name:
Company:
Phone:
Fax:
E-mail:
Borrower Information
First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code:
(5 digits)
State:
AL
AZ
AK
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Co-Borrower Information
First Name:
Last Name:
Contact Information
Daytime Phone:
Evening Phone:
Email:
Financial Information
Loan Type:
Purchase
Refinance
Home Equity
Loan Amount:
(USD)
Property Information
Address Line 1:
Address Line 2:
City/Town:
Zip Code:
(5 digits)
State:
AK - Alaska
AL - Alabama
AR - Arkansas
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - Washington DC
DE - Delaware
FL - Florida
GA - Georgia
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MI - Michigan
MN - Minnesota
MO - Missouri
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
Not USA
Property Type:
Single Family Residence
Duplex
Mobile
Condo
Townhome
Occupancy:
Primary Residence
Secondary Investment
Investment
Purchase Price:
(USD)
Appraised Value:
(USD)
Mortgage Balance:
(USD if applicable)
Purchase Information
Title Preference:
Joint Tenancy
Tenants in Common
Tenants by the Entirety
Individually (single owner)
Attorney Name (if not Maine Title Services):
Attorney's Address:
City/Town:
Zip Code:
(5 digits)
State:
AK - Alaska
AL - Alabama
AR - Arkansas
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - Washington DC
DE - Delaware
FL - Florida
GA - Georgia
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MI - Michigan
MN - Minnesota
MO - Missouri
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
Not USA
Attorney's Phone #:
Insurance Agency (Homeowner's):
Agency's Phone #:
Refinance Information
Current First Mortgage Lender:
Loan/Account #:
First Lender's Phone#:
Current Equity/Second
Mortgage Lender:
Loan/Account #:
Second Lender's Phone #:
Other Information