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Borrower
Date of Birth
Co-Borrower Date of Birth
POA
, Guardian,
or
Conservator
(if used)
Property Address
(if a P.O. Box is used - enter it in the comment section below)
City State Zip
Property Value Total Liens
(including Judgments & Mortgages)
Phone
#
(The best # to reach you)
Fax #
(If a fax is available)
Alternate Phone Number
(Optional)
Email Address
(if available and readily accessible)
Best time
to Schedule Counseling Appt:
Your Time Zone:
Anytime
Morning Daytime Evening
Eastern Central Mountain Pacific
Comments
Loan Officer Name
Have
you completed a loan application?
Lender Name
Yes
No
Email:
Counseling@866reverse.com
Fax: 866-738-1715
