Northeast Title And Abstract Co.

84 Everett Road
Albany, New York 12205
Phone: (518) 458-8400
Fax: (518) 458-9343


Dated Ordered _______________			Ordered By _____________________________

Report Due Date _______________		  Anticipated Closing Date _____________________

Applicant's Name(s) ____________________________________________________________________

Address ________________________________________________________________________________

Phone Number Home _________________		Work Phone _____________________________

Circle One:	Purchase	or	Refinance

Property Address _______________________________________________________________________

City/Town ______________________________	County ________________________________

Current Owner(s) _______________________________________________________________________

Source Deed Book ________________________________	Page _______________

Mortgage Amount $___________________	  Purchase Price $_________________

Insured Lender _________________________________________________________________________

Lender's Attorney ______________________________________       Phone ___________________

Seller's Attorney ______________________________________       Phone ___________________

Buyer's Attorney _______________________________________       Phone ___________________

Existing Mortgage Held By ______________________________   Loan Number _________________

Surveyor _______________________________________________________________________________

Additional Information _________________________________________________________________

    ____________________________________________________________________________________

    ____________________________________________________________________________________