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The information that is provided on this form is confidential and is only for use by Prominent Title Agency. This information will not be given or sold to any third parties.


Loan Officer:
Company:

Lender Contact:
Lender Fax:
Lender Phone:
Lender Email:

Who will investor be?:

Borrower 1:
Social Security:
Borrower 2:
Social Security:
Home Phone:
Work Phone:
Cell Phone:

Property Address:
City:
State:
Zip Code:
County:
Loan Amount:
Sale Price:
Earnest Money:

Seller 1:
Home Phone:
Work Phone:
Cell Phone:
Seller 2:
Home Phone:
Work Phone:
Cell Phone:

Selling Realtor:
Company:
Selling Realtor Phone:
Selling Realtor Fax:
Selling Realtor Cell:

Listings Realtor:
Company:
Listings Realtor Phone:
Listings Realtor Fax:
Listings Realtor Cell:

Commission Amount:
%
Commission Held By:

Title Company Order Payoffs?: .. Yes .... No

1st Mortgage With:
Account Number:
2nd Mortgage With:
Account Number:

Survey Required?: .. Yes .... No
Purchase Contract Attached?: .. Yes .... No
Borrowers Authorization Sent?: .. Yes .... No

Estimated Closing Date:

Notes or Comments:

....


Prominent Title Agency, LLC.
7365 East Kemper Road, Suite B • Cincinnati, Ohio 45249
Phone: (513) 779-7714 • Fax: (513) 779-7738

©2008 Prominent Title Agency, LLC. All Rights Reserved....