1st Mortgage:

Balance: $	Interest Rate:	Original Loan Amount: $
Original Amortization/Term: (e.g. 30 yrs, 15 yrs, etc)	Date Settled: (month/year)	Loan Type: (e.g. fixed or adjustable)

2nd Mortgage and/or other liens:
(if applicable)

Balance: $	Interest Rate:	Original Loan Amount: $
Original Amortization/Term: (e.g. 30 yrs, 15 yrs, etc)	Date Settled: (month/year)	Loan Type: (e.g. fixed or adjustable)

For Cash-Out Customers Only:

Amount Needed: $

When needed?

Personal Information:

Your Name:	Your Work Phone Number:
This is not for solicitation purposes - only for possible further needed information	Your Home Phone Number:

How would you like to be contacted with the results?

After completing this form, you can either print it and mail/fax it to PMC, or you may electronically submit this information directly to our server. All your information will be kept confidential and will not be released to non-authorized personnel. If you wish to electronically submit this form, please click on the "Submit" button below when you are finished completing the form.

By submitting this form with your telephone number you are consenting for Laurence Ostrom and all authorized representatives to contact you even if your name is on a Federal or State "Do not call List."