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Please type or print on form 

Full name(s) and Date of Birth of  Buyer(s).  Please indicate names as you wish same to appear on the Deed.

Buyer 1’s name                                                                            Buyer 1’s DOB                                               

Buyer 2’s name                                                                            Buyer 2’s DOB                                                                                    


Buyer 1’s Social Security Number                                                   Buyer 1’s DLN#                                          

Buyer 2’s Social Security Number                                                   Buyer 2’s DLN#                                                  


Buyer 1’s present address:




Buyer 2’s present address: ( If same as Buyer 1 just fill in “same as above”)



Maiden Name of Wife:                                                                   Date of Marriage:                                                            

Home telephone number:  (      )                                                                                 


Work telephone numbers:  (      )                                                     (      )                                                         


Cell phone numbers:   (      )                                                             (      )                                                         

E-Mail:                                                                                       Fax:   (    )                                                                                             


Desired Closing Date:                                                                    Estimate Move-in Date:                                                        

Name, address and telephone number of Lender for proposed mortgage loan:


                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Name of Mortgage Processor:                                                                                    

Formerly married to:                                                                    

How marriage terminated:                                                          

Date marriage terminated:                                                                           


Formerly married to:                                                                         

How marriage terminated:                                                                 

Date marriage terminated:                                                                

Is the property you are purchasing in a homeowner’s association or community association?  If yes, please provide name address and telephone number of same. 


Have either Buyer 1 or Buyer 2 ever declared Bankruptcy.  If, yes please provide date of  discharge, type of Bankruptcy Chapter filed, Court filed in and docket number. 


Child Support:  Please indicate if any judgments for the payment of child support exist with reference to either Buyer 1 or Buyer 2.


Indicate if any judgments have been obtained against Buyer 1 or Buyer 2. 


Survey data:  You must confirm in writing if you will require corner staking of the property being purchased.  The survey customarily costs approximately $575.00- $750.00(under one acre);  with an additional cost of $75.00 per stake for each corner stake.  Kindly complete the following and sign indicating whether or not property is to be staked. 
_____  I do require property corner stakes set by surveyor. 
______ I do not require property corner stakes set by surveyor.  

Dated:  _____________                                __________________________________________

                                                                        Buyer 1

Dated:  _____________                                __________________________________________

                                                                        Buyer 2