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Full Name (required)

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Phone (optional)

Property Address, City, State, & Zip (required)

Type Of Property (required)

Are you the Owner of the note? (Y/N) (required)

Is this a Refinance? (Y/N) (required)

If Refinance, what is the current balance? (required)

Sales Price (required)

Down Payment (required)

Interest Rate (required)

Monthly P&I Payment (required)

Date First Payment Made (required)

Current Balance (required)

Current Paid Thru Date (required)

Payments Current? (Y/N) (required)

Balloon Payment? (Y/N) (required)

If there is a balloon payment, when is it? (provide date) (optional)

Months Delinquent (required)

Is this a Re-Performing loan? (Y/N) (required)

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