Agent's Name *

Agency/ Brokerage *

Phone *

Fax Number

Please leave this field empty.

Email *

Property Address *

Property City *

Property State *
---OhioKentuckyIndianaTennesseeMichiganMinnesotaWisconsin

Property Zip *

Purchase Price *

Broker Fees *

Selling Commission *

Listing Commission *

Marital Status *
---SingleMarried

• Ohio dower law requires the spouse’s signatures on deeds even if they are not an owner. Dower does not cease until final a final decree of divorce is filed with the court.

• If any required signor will not be available at closing please alert us as an approved POA will then be required.

Seller's Name *

Title of Property Currently Held By *
---Individual(s)LLCTrustCorporationPartnership

Seller's Forwarding Address *

Please leave this field empty.

Seller's E-mail *

Seller's Phone *

Is The Property Subject To a HOA? *
---YesNo

Number of Open/Unpaid Mortgages *
---None12345+

Deed prepared by *
---Thru Fidelity Land TitleOther*

*If seller is providing deed, please fax or e-mail to Fidelity Land Title at least 3 business days prior to closing.

Does your seller have an Owner’s Title insurance policy from when they purchased the property? *
---YesNoUnsure

Has your seller ever obtained a survey during their time owning the property? *
---YesNoUnsure

Are you aware of any estate/bankruptcy/divorce/civil legal proceedings during your clients ownership? *
---YesNoUnsure

Does the property have a shared driveway/private access road with the neighbors? *
---YesNoUnsure

****************** Seller Authorization to Obtain Payoffs ******************

We will need written authorization from the seller in order obtain payoff statements from the lender(s). Most lenders still require hand written signatures. Please indicate below whether you would like to obtain the information and signatures or whether you would like us to contact the seller directly. We will contact the party selected and provide them with the authorization form and secure means to get the information back to us.

Payoff Authorization Form Delivery *
---I will obtain this information w/ the form provided by FidelityPlease contact my seller via e-mail*

*If you would like us to contact your seller directly, please let them know ahead of time to be expecting Fidelity Land Title to contact them with this authorization form.

Any additional info your would like us to know about your property/title

Document Upload (Addendum's,Trust/LLC docs, Corp Resolutions, Surveys, ect....)
(Max 12MB, File Types: .gif, .png, .jpg, .pdf, .xls, .doc, .docx)

What is the sum of 2 and 4?