NIA/Lawyers Title Agency, LLC

Date Ordered:___________ Commitment Date:__________ Case No:_________

Applicant:_______________________________
Company/Firm:_______________________
Address:__________________________________
City, State, Zip:__________________________
Phone:_______________________
Email:________________

Property Address:
Street:________________________________ Lot:______ Block:__________
Municipality:__________________________ County:_____________________
Condo:_______________________________ Unit No.:____ Bldg:_______

Present Owner:______________________________
Buyers/Mortgagors:_____________________________________________
Maiden Name:_________________
Address:__________________________________
City, State, Zip:__________________________
Phone:_______________________
Fax:_________________________
Email:________________
Purchase $:_____________________

Sellers:_________________________________________________________________
Marital Satus:__________________________
Address:__________________________________
City, State, Zip:__________________________
Phone:_______________________
Fax:_________________________
Email:________________

Lender:_______________________________
Contact:_______________________
Address:______________________________
Phone: (____)_____-_________
Fax: (____)______-__________
Mortgage $ __________________

Survey:
NIA:______ Attorney:________ Affidavit:__________ Waived:________ TBA________

Flood:
Yes:______ No:________ Life of Loan:__________

Sellers Attorney:_______________________________

Prior Title Information:_______________________________

Comments:________________________________________________________
_________________________________________________________________
_________________________________________________________________
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