ATTENTION PHONE REPS: THIS FORM MUST BE ENTIRELY COMPLETED ON ALL INCOMING CALLS!!  A representative will make a callback in 24-48 hours to discuss the details if we are interested in buying their house.

Name :
Current Mailing Address :
City :
State :
Zip Code :
Phone :
Email - (type none@none.com if you dont have an e-mail address) :
What is the address of the property you are selling?  :
What kind of house do you have for sale? :	Single Family Townhouse Row house Semi-Detached Other
Name of Development where home is located :
Why are you selling? :
What is the approximate 1st mortgage balance? :
Amount of 2nd Mortgage or Equity Mortgage - if any? :
What is/are the current mortgage payment(s)?  :
Is/Are the loan(s) behind in payments? :	Yes    No
If late, how many months? :
Does the house need repair?  :	Yes    No
What is the cost of the repairs? :
Please describe what repairs are needed  :
How many bedrooms and bathrooms? :
How long have you owned this house? :
Is the house vacant or occupied?  :	Vacant    Occupied
What are you asking for the house? :
What amount do you think it would appraise for?  :
How did you hear about us? :	Shopper's Guide Newspaper Street Sign 40 Flyer Newspaper Middletown Transcript Newspaper Squirt Bottle in Mail CD in Mail Postcard in mail A Flyer in a store Next Level Magazine Received a Flyer in mail Billboard Letter in mail Radio commercial Verizon Phone Book Yellow Book Yellow Pages Phone Book Business Card Car Sign Internet TV Commercial Referral Door Hanger Flyer
Any additional information about the house or your situation :
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