SELLARS INFORMATION STATEMENT

                             Userid EMAIL
NAME LAST   FIRST   PHONE   HOME   WORK

ADDRESS

SOCIAL SECURITY NUMBER:   H:   W:
IS EITHER SPOUSE OVER 62    YES  NO    NAME  
MARITAL HISTORY
DATE OF MARRAGE:  MAIDEN NAME OF WIFE:
PREVIOUS MARIAGE
YES  NO
IF YES SEND COPY OF JUDGEMENT(S) OF DIVORCE TO YOUR LAWYER OR PROVIDE NAME AND DATE OF DEATH OF PREVIOUS SPOUSE   NAME DATE 

ADDRESS OF SUBJECT PROPERTY

TAX LOT:   TAX BLOCK: 
TYPE OF RESIDENCE:
IF MULTI FAMILY NUMBER UNITS
TYPE OF FUEL:
PROVIDER:
MORTGAGES AND EQUITY LOANS  PLEASE SUPPLY NAME ADDRESSES OF INSTITUTIONS TOGETHER WITH ACCOUNT LOAN NUMBERS AND CUSTOMER SERVICE TELEPHONE NO.
NAME 

ADDRESS

ACCOUNT / LOAN #
CUST-SERVICE TEL #
NAME

ADDRESS

ACCOUNT/LOAN #
CUST-SERVICE TEL #
NAME

ADDRESS

ACCOUNT/LOAN #
CUST-SERVICE TEL #
NAME

ADDRESS

ACCOUNT/LOAN#
CUST-SERVICE TEL #
IF RESIDENCE IS A CONDIMINIUM, TOWNHOUSE, CO-OP OR OTHER PLANNED DEVELOPMENT, PLEASE FURNISH NAME, ADDRESS AND PHONE NUMBER OF THE ASSOCIATION AND/OR MANAGEMENT OFFICE, AS WELL AS CONTACT PERSON
NAME 

ADDRESS

CONTACT PERSON
PHONE #  

SELLARS FORWARDING ADDRESS

*BACK TITLE: PLEASE PROVIDE COPIES OF (a) DEED: (b) SURVEY: (c) TITLE INSURANCE POLICY