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Name*		Day Phone*	Evening Phone*
Email Address*		Street Address*
City*		County* -Choose A County- Gwinnett County Fulton County Other County
State*	Zip Code *	Subdivision Name (if any)
How did you hear about us? Street Sign Newspaper Ad News Article Post Card Letter Ad Magazine Flyer Grocery Shopper Car Sign Search Engine Internet Ad Radio Billboard Business Card Referral Other
Let's talk about the numbers...
How much do you owe on your house?* How much is the house worth?*
1st Mortgage Balance*	1st Mortgage Payment*	1st Mortgage Holder*
2nd Mortgage Balance	2nd Mortgage Payment	2nd Mortgage Holder
Do you have an equity line on this house?
Balance	Payment	Holder
So the total monthly payment is* Are the payments current? yes no If no, how far behind? (If you don't know for sure, can you estimate?) jkljl 1st Mortgage # of pmts/months $ amount Penalities/Fees included? yes no 2nd Mortgage yes no Equity Line yes no Date received Have you received a foreclosure warning letter from your lender? yes no Have you received a Notice of Foreclosure? yes no Has a Foreclosure Sale Date been set?  yes no If yes, what is the sale date? Is the house attached to a bankruptcy? yes no Are there any other comments you have that would enable us to help you better? Is the house occupied unoccupied Does the house need repairs? yes no If "yes," what kind? Describe your house... Ranch 2-Story Split Foyer Split Level Sq. Footage All Brick Brick Siding Wood Siding Vinyl Siding Stucco Lot Size # of Bedrooms # of Baths Formal Living Rm Formal Dining Rm Fireplace Ceiling Fans Fenced Pool Sewer Septic Crawl Space Slab Basement Finished Age of Roof Unfinished Central Air Number of Units Garage On-Street Parking Number of Cars Carport Off-Street Parking When was the house built? How long have you owned the house? Is the house listed with a real estate agent? yes no If yes, when does the listing expire?