Land Title of America Group
Phone (904) 829-6600 ( FAX (904) 824-2870

Address of Property: ________________________________________________________________
Parcel #: __________________________________ Improvement or Vacant? _________________
Sellers Information:
Full Name: __________________________________________________________________________
Current Mailing Address: ____________________________________________________________
Home Phone: ___________________ Work 1: __________________ Work 2: __________________
Will seller be present for closing?       Yes        No      
Marital Status: ____________ Sellers SSN: ___________________ Spouse's: _____________
Attorney Information (if applicable): ________________________ Phone: _______________
Payoff info:
Name of Payoff #1: __________________ Loan #: ______________ Phone: _________________
Name of Payoff #2: __________________ Loan #: ______________ Phone: _________________
Notes:  _____________________________________________________________________________
 ____________________________________________________________________________________

     If we need any additional information about the seller, Land Title needs to:
  Contact the listing broker -  (Please circle one)  - Contact the buyer(s) directly

Buyers Information:
Full Name: __________________________________________________________________________
Current Mailing Address: ____________________________________________________________
Home Phone: ___________________ Work 1: __________________ Work 2: __________________
Will seller be present for closing?       Yes        No      
Marital Status: ____________ Sellers SSN: ___________________ Spouse's: _____________
Attorney Information (if applicable): ________________________ Phone: _______________
Notes: ______________________________________________________________________________
_____________________________________________________________________________________

     If we need any additional information about the seller, Land Title needs to:
  Contact the listing broker -  (Please circle one)  - Contact the buyer(s) directly

New Loan Information:
Lender: ______________________________       Loan Broker: ____________________________
Phone: _______________________________       Phone: __________________________________
Contact: ______________________________      Contact: ________________________________
If Seller financed, need terms of mortgage:
_____________________________________________________________________________________

Property Information:
Association Dues?      Yes     No                  Rent Prorations?      Yes      No
Name/Contact: ___________________________          Amount of Rent: ________ Due: _____
Phone: ______________ Amount: ___________          Deposit Amount: ___________________
                                                   Held where? _______________________

Home Warranty?        Yes        No                Other Perorations?    Yes      No         
Name: ___________________________________          Amount: _____________ Due: ________
                                                   Held where? _______________________
Is this a mobile home?       Yes        No
Who has the titles to mobile home?  __________________________________________________
Broker Information:     
Listing Broker                               Selling Broker
Office Name: ____________________________    Office Name: ____________________________
Agents Name: ___________________________     Agents Name: ____________________________
Phone/FAX: _____________/_______________     Phone/FAX: ______________/_______________

Commission percent __________ Listing percent ___________ Selling percent _____________
Deposit Amount: ________________________ being held by: _______________________________
Title Insurance Quote:  _______________________________________________________________