F&M Title and Escrow

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Check One:

	* Purchase		** Refinance
* On all purchases, please fax a copy of the sales contract ** With ALL settlement requests, please provide a copy of the loan application

Owner(s)/ Borrower(s):

Property Address / Legal Description:
Please note that a * denotes a required field.

* Address One:

Address Two:

* City:

* State Abbreviation:

* Zip Code:

Lot #:

County:

Seller(s):

(if applicable)

Settlement Requested By:
Please note that a * denotes a required field.

* Check One:

Lender

Realtor

* Company Name:

* Contact Name:

* Contact Number:

- -

* Email:

Loan Amount:

$

2nd Trust Lender (if applicable):

Targeted Settlement Date:

Comments:

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