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Submission Form

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Personal Information

Owner's/Co-Owner's Name(s):
Your Mailing Address:
City, State, Zip
E-mail: ( 1 only)
Home/Work/Cel Nos:
Best Way To Contact is via:
Were you referred to us? If so, by whom:

Property Information

Address
City, State, Zip

Is The Home Listed By Realtor?
If yes, Realtor's Name / Phone

Information About Existing Loans

1st mortgage balance $
Lender
Loan Number
2nd Mortgage Balance $
Lender
Loan Number
Purchase Price $

Comments & other information, if applicable:

General Information:

Do you Live There?
If no, is it rented?
Has the Lender(s) started foreclosure?
Is there a Homeowner's Association?

For your convenience, we can send your documents Electronically as an Email attachment in Adobe Acrobat .

Please indicate if you want them sent to you in hard copy by FEDEX or as an attachment to Email.

FEDEX

Email Documents

I authorize Wilshire Holding Group, Inc. to charge my credit card the amount of $100.00 to cover cost of document preparation. I understand that this is a non refundable charge but will be applied toward my total fee of One Percent (1%) of my current loan(s) amount with a minimum fee $1,000 and a maximum fee of $4,000.

Type of Credit Card
Name as it Appears on Card
Card Number
Expiration Date	Card ID

Tel: (877) 255-1074 - Fax: (800) 291-4555