Name:Address:

City:       State: Zip:

County of Residence:         

Day Phone:  ()          Evening Phone: ()

FAX Phone:  ()          Work Phone:    ()

Best time to call: A.M.    P.M.    Eastern    Pacific    Central

E-mail address:    Social Security No.:

Are you?  The Note Holder    Note Broker    Real Estate Agent

                      Referral Source      Other:

Do you have a signed contract to buy or broker this mortgage?      Yes      No

Property address:

City:       State: Zip:

County         

Property type:    Single Family Residential     Duplex     Multifamily    Condo   

                          Owner occupied    Rental    Vacant

                          Developed Land    Undeveloped land  

                          Other: (describe)

Description of property: 

Is this a Simultaneous Closing?      Yes       No

     Sales Date:           Sales Price:

Down Payment:  Appraised Value:

 Current Value:  

Do you want a    Wholesale    Retail quote?

Do you want to sell the whole note   just the balloon   partial payments.

If partial:  I want to sell payments.

Check applicable box:

First Mortgage                                                            Second Mortgage  

Payor Name (s)                                                                  Payor Name (s)

Fico Score:                                  Fico Score:        

Date of Mortgage:                        Date of Mortgage:

Original Balance:                          Original Balance:  

Terms in Months:                           Terms in Months:            

Interest Rate:                                  Interest Rate:      

Payment Amount:                           Payment Amount:

Date of first payment:                Date of first payment:

Date of next payment:                Date of next payment:

Balloon Date:                             Balloon Date:           

Balloon Amount:                        Balloon Amount:       

Number of Payments Left:                 Number of Payments Left:

Current Balance Date:                Current Balance Date:

Current Balance Amount:                 Current Balance Amount:

Describe Collateral:                                                          Describe Collateral:

   Payments on time    Late a few time    presently in arrears 

Explain:

Have you ever used a cash flow broker before?    Yes     No

Have you been shopping this deal?  If  yes, what is the highest bid you received?

Who gave this bid to you?

Search Engine------------Name of search engine:        

Keywords Used--------------

Banner Ad----Where did you see our banner?

Classified Ad---------Where did you see it? 

Newsgroup--------------Which newsgroup?

Other: -----