Note Information (Note Holder)

First Name: Middle Initial

Last Name:

Address:    

City:State:

Zip:

County:

Phone Number ()  -   Ext:

Email: 

Person making the referral.  Same

First Name: Middle Initial

Last Name:

Address:    

City:State:

Zip: 

County:

Phone Number ()  -   Ext:

Email: 

Note Category   $ $0 -$50K $50K - $100K $100K - $150K $150K - $200K $200K - $250K $250K +

                         Type of Property Pick One Single Family Residence Mobile Home w/Land Mobile Home w/o Land Multiunit (Duplex,etc) Condominium Lot (In Sub. w/Utilities Vacant Land (w/o Utilities) Business Boat Ariplane Other  Owner Occupied Y/N Pick One Yes No N/A

Property Address (No P.O. Boxes please)

City   State      Zip

County

Date of Sale :   (m/d/yyyy)

Property Sold For $

Down Payment: $

Original Balance of Note (Face Value): $

Amortization Period :  Years

Interest Rate:   %

Payment Amount:  $ (P&I)

Balloon Payment:   Due Date If Applicable: (m/d/yyyy)

Amount If Applicable:$

Date of First Payment:  Date of Next Payment:   (m/d/yyyy)

 Payments Are Made: Pick One Monthly Quarterly Semi-Annual Annual

Number of Payments Made to Date:                        Number of Payments Remaining:

Position of Note: Pick One 1st 2nd other

Payor’s Credit Score:   Pick One 700+ 600 - 699 500 - 599 Below 500 Unknown    Number of Late Payments  Pick One None Unsure, more than 1 1-5 6-10 11-15 More than 15

Current Note Balance: $

Current Property Value:$    --(Check one -- Estimate  Appraisal)

Status of Note is Pick One Current Delinquent

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