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C O N F I D E N T I A L
Your Contact Information
*Your First Name
*Your Last Name
*Your Email
Day-time Phone Number
* What's your situation? Why are you selling?
When do you need to sell your house?
Property Information
Street Number
Street Name
Zip
City
State	... Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming
Is the house currently listed with a ®Realtor?	Yes  No
If Yes, when does the listing expire?	January February March April May June July August September October November December 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 mm/dd/yyyy
If No, has the house been previously listed?
What kind of repairs or maintenance does the house need?
How much do you think these repairs will cost?	$  e.g. 5000 (not 5,000)
Property Type	Single Family House Duplex TriPlex 4-Plex Multi-Family Commercial Property Land Other Multiple / Combo Townhome Condo Patio Home
Approx. Square Feet
Year Built
Bedrooms
Bathrooms
Garage?	Yes  No
Is it Vacant?	Yes  No
Price And Terms
1st Mortgage  2nd Mortgage  3rd Mortgage  Balance  $  $  $ e.g. 5000 (not 5,000)  Monthly Payment  $ $   $ e.g. 5000 (not 5,000) Interest Rate     %   %   % Are Payments Current?   Yes  No   Yes  No   Yes  No If Not How Far Behind?  $  $  $ e.g. 5000 (not 5,000)
Total Lien Amount (if more than 1, list each separately)?
*If we were to have your house appraised, how much do you think it would be worth?	$
Would you sell your house for what you owe on it?	Yes  No  Undecided
Would you be willing to receive any of your equity, if applicable, in the form of monthly payments?	Yes  No  Undecided
Would you be willing to sell your house by allowing us to take over your monthly mortgage payments?	Yes  No  Undecided
* If we were able to buy your house in 7 Days or less, what is the least you could accept?	$  e.g. 5000 (not 5,000)
How did you hear about us?
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