10434 Lovell Center Drive
Knoxville, Tennessee 37922
865-963-0156 phone
865-934-0104 fax
Legacytitleagency.com
FROM: (Company) _________________________________________ PHONE: ________________________
CONTACT: _______________________________________________ FAX: ________________________
BORROWER INFORMATION
Borrower(s): _______________________________________________________________________________
Property Address: ___________________________________________________________________________
City/St/Zip: _______________________________________________________________________________
COUNTY: __________________________________________________
Borrower Phones: Home: _________________ Work: _________________ Cell: __________________
Borrower(s) SS#: __________________________________________________________________________
SELLER INFORMATION
Seller(s): _______________________________________________________________________________
Loan Amount: $________________________ Sales Price: $__________________
Proposed Insured: ___________________________________________________________________________
SERVICES REQUESTED
ESTIMATED CLOSING DATE: _____/____/2005
_________ Title Insurance
_________ Closing
_________ Order Survey
_________ Order Payoff
LENDER INFORMAITON
Lender: _____________________________________________ Acct #: ______________________________
Lender Phone (if any): __________________________________
*If you have requested a payoff, you must have the above filled out in full and provide us with borrower's authorization.