Seller's/Owner's Full Names (if this is a refinance enter the current owner's names here)

Buyer's Full Names (if this is a refinance, leave this space blank)

Legal Description of Property
(enter as complete a legal description as you can, NOT A STREET ADDRESS)

Is there an existing title policy? Yes: No:
If yes, please enter who the current policy is with and the policy number if available.

Proposed Insured (name of bank and/or buyers names as they wish to be shown on deed)

Owner's Policy Amount   $    (if loan policy only, leave this space blank)
Mortgage Policy Amount $    (if owner's policy only,  leave this space blank)
Is this a combination Owner's and Loan policy?   Yes:     No: 
Type of Loan:       Conventional/In House      VA     FHA      Construction 
Short form loan Policy:     Yes:       No:
Is this to be a 6 month construction commitment only?      Yes:       No:

Where to send the complete title commitment:

Special Instructions or Comments: