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Name
Date
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Fax
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Current Estimated Value ($)
Based On
Residential Type —Please choose an option—Single-familyMobile Home & LandMulti-family (2-4)Mobile Home Only
Occupancy Type —Please choose an option—Owner-occupiedRentalVacant
Commercial (Type)
Vacant Land (Acreage & Improvements)
Description of Property & Area
Date of Sale
Selling Price
Down Payment
First Lien
Second Lien
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Date of Note
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Term in Months
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Balloon Amount
Balloon Date
Interest Rate
Name, Address, SSN, or Credit Information
Due Date 1st Payment
# of Payments Paid
# of Payments Left
Next Payment Due
Balance
Referral Referral
Retail Retail
Wholesale Wholesale
Buy Total Note
Buy _____ Payments for _____
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