Hometown Title, Inc.
Title Policy Order Form


Office:

Date Submitted:Closing Date:
Submitter:Email Address:
Copies to:
Email Copies to (Email Addresses):    

Seller Information:
Last:First:M.I.:
Last:First:M.I.:
Current Address:Telephone No:() -
Forwarding Address:Telephone No:() -
Marital Status:
Single     Married     Divorced     Remarried     Widow(er)    Partners in a civil union
    County of death:
Attorney:Telephone No:() -   Fax No: () -
Realtor:Listing Company:
Telephone No:() - Fax No:() -
Commission %:Commission Split:
Seller authorizes deed preparation by Benckendorf & Benckendorf, P.C.: Yes No
Seller will provide prior: Title Policy Mortgage Policy Abstract

Buyer Information:
Last:First:M.I.:
Last:First:M.I.:
Current Address:Telephone No:() -
Marital Status:
Single     Married     Divorced     Remarried     Widow(er)    Partners in a civil union
Taking Title as: Joint Tenants     Tenants by Entirety     Tenants in Common     Individual
Attorney:Telephone No:() -   Fax No: () -
Realtor: Listing Company:
Telephone No:() - Fax No:() -
Commission %:Commission Split:

Property Information:
Address:     P.I.N.:
Short Legal Description:  
Sales Price:Possession Date:     Principal Residence: Yes   No
Termite Inspector:Insp. Cost:
Earnest Money:Holder:

Mortgage Information:
Lender:     Amount:
Branch Address:
Loan Officer:Telephone No:() - Fax No:() -
Endorsements: Location Note     EPA     Comprehensive     Other:  

Additional Comments: