First Name: Last Name:  
City: County:  
State: Zip Code:  
Day Phone: Night Phone:  
1)   Are you subject to any IRS Notice of Lien? Yes   No
2)   Any judgments against you? Yes   No
3)   Any mechanics liens on the property? Yes   No
4)   Any State Tax liens on your property? Yes   No
5)   Any HOA dues unpaid? Yes   No
6)   Any encumbrances on the property beyond your mortgage(s)? Yes   No
7)   Are there any legal suits pending against you or other signor on note or owner of property? Yes   No
8)   Are you divorced or separated and if so is former spouse on the deed and on the note? Yes   No

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