| Tell Us About You… |
| First Name: |
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| Last Name: |
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| Address Street 1: |
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| Address Street 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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| Contact Information |
| Daytime Phone: |
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| Evening Phone: |
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| Email: |
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| Tell us about the property… |
| Property Type: |
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| Occupancy: |
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| Property street address: |
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| Property State: |
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| Property city: |
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| Purchase Price: |
(USD) |
| Appraised Value: |
(USD) |
| What is the general condition of the house: |
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| Garage:: |
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| Age of House: |
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| Square Footage: |
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| # of Baths: |
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| # of Bedrooms: |
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| Please describe any needed repairs in this box: |
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| Mortgage Balance: |
(USD) |
| Check All That Apply: |
Game Room |
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Tile |
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Deck |
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Formal Dining Room |
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Carpeting |
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Wood Floors |
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Fireplace |
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I authorize DFW Real Mentor, L.L.C to verify
my credit and employment history. |