Print this Form, Fill it out, then Fax it to David Protiva at
Atlanta Real Esate and Mortgage Co.
(404) 351-5772
Your name:_________________________(w)phone________________
(h) phone__________________________ pager___________________
Seller's Name (if different from
above):__________________________
Seller's Work Phone:________________________________________
Borrower's Name:__________________________________________
Property Address:__________________________________________
Subdivision:_______________________County:_________________
Borrower Works At:________________________________________
Borrower's Work Phone:____________________________________
Borrower's Soc. Sec. #_______________________________________
Original Sale Price and sale date: $_____________date:__________
Estimated Current value: $_______________________________
Estimated 1st Mortgage Balance:_____________________________
Estimated 2nd Mortgage Balance:____________________________
Terms of 2nd Mortgage:____________________________________
# of payments made: ________ date last payment received:
______
# of payments made on time - 30 days: _______________________
# of payments made 30 - 60 days late: _______________________
# of payments made 60 - 90 days late: _______________________
# of payments made > 90 days late: _________________________
Other information you may know about Credit History of Borrower:
______________________________________________________
______________________________________________________
______________________________________________________