Contact Information

First name: Last name:

Home phone/Area code: Number:

Cell phone/Area code: Number:

Email address:

Mailing/Street address: Unit #:  

City: State: Zip code:

Property Information

Property previously on the market? Yes No  

How long:   Price:   Why are you selling? 

Sell to buy  Larger home  Smaller home Death Finances  

Bankruptcy  Retirement  Investment - Other:

Relocating  -  where:

What kind of property do you have?

Condo     Townhouse     Single Family     Land     Commercial

 #/Bedrooms:       #/bathrooms:      Sqft:     

Pool     Spa    Other:  

 Zoning/Land & Commercial only:  

Selling property/address: Same as above     (If different fill out address below.)

Selling property/Street address:  

Unit #:  

City: State: Zip code:

Loan and debt information

How much do you owe? 

1st loan: 2nd loan: 3rd loan:  

Do you owe back taxes? If so, how much?   

Any other loans/debts?  Loan default? Yes No  

Have you filed bankruptcy? Yes No  -  If so, when:

What type of Listing Plan interests you?

Basic Deluxe Full Service Short Sale  Loan Modification 

Remodel  Don't know

Can you tell us more?

Any idea of how much your property is worth?      

If so, how did you determine the value? Neighbor's House     Appraisal    

  Refinance     Realtor     Other:

When are you ready to sell?

Now        30 days        90 days        6 months        1 year

What questions do you have?

  Brief survey

How did you hear about us? Internet TV/cable Newspaper  Homes

& Land Magazine Yard sign  Bus bench    US mail  Email message 

Past client        Other: