Borrower:      Date:

Requested by:     Phone:

Address:     City/State/Zip:

Property Address:    

Property City/State/Zip:

Legal Description:

Access Name:

Work Phone:     Home Phone:

Type of Loan:  First Mortgage      Second Mortgage      Refinance

Amount of Loan:     Loan Term:

Sales Price:     Date of Sale:

Remittance: Company   Owner   Cash   Citicorp/Citibank:  yes   no

Comments: