Email Address 

My/Our Name and Marital Status is as follows:
(Name)
single person OR  (check one) married person
If married, name of spouse is : 

(If additional owners are on title please continue)
Name 
single person OR  (check one) married person
Name of Spouse if Married

Name 
single person OR  (check one) married person
Name of Spouse if Married

Name 
single person OR  (check one) married person
Name of Spouse if Married

Name 
single person OR  (check one) married person
Name of Spouse if Married
 

This property is not, nor has it ever been my/our homestead nor is it contiguous to any of our homestead property, and I/We will warrant the same in the Deed of conveyance to the Buyer.

MY/OUR FORWARDING ADDRESS AFTER CLOSING IS AS FOLLOWS:
Address 
City  State 
Zip Code 

Social Security number for: (name) 
is :(no spaces)
Social Security number for: (name) 
is :(no spaces)

(If there are additional Social Security Numbers, please list here)
Social Security number for: (name) 
is :(no spaces)
Social Security number for: (name) 
is :(no spaces)
Social Security number for: (name) 
is :(no spaces)
Social Security number for: (name) 
is :(no spaces)

I/WE ARE FOREIGN SELLERS AND HAVE NO U.S. SOCIAL SECURITY NUMBERS.

IF A FOREIGN PERSON: (please check)  I UNDERSTAND THAT 10% OF THE PROCEEDS FROM THE CLOSING WILL BE WITHHELD FOR FIRPTA. (please check)  I FURTHER UNDERSTAND THAT THIS 10% WILL BE FORWARDED TO THE INTERNAL REVENUE SERVICE WITHIN 10 DAYS AFTER CLOSING, UNLESS A FIRPTA EXEMPTION APPLICATION OF THE WITHHOLDING IS FILED PRIOR TO CLOSING. I FURTHER UNDERSTAND THAT IF A FIRPTA EXEMPTION APPLICATION IS FILED PRIOR TO CLOSING THAT DUNN TITLE WILL HOLD THE 10% WITHHOLDING IN THEIR ESCROW ACCOUNT UNTIL A FINAL DECISION IS MADE BY THE INTERNAL REVENUE SERVICE.
 

I/WE HAVE A 1^ST MORTGAGE ON THIS PROPERTY   yes   no
(Name of Bank/Mortgage Company) 
Loan No.: 
Please provide address & phone number for us to order the Pay-Off.
Address 
City 
State 
Zip Code 
Phone Number 

Next Payment Due:
When will you be making payment?

I/WE HAVE A 2ND/EQUITY LINE MORTGAGE ON THIS PROPERTY 

yes no
(Please supply us with the information even if you have a zero balance on the account)
(Name of Bank/Mortgage Company) 
Loan No.: 
Address 
City 
State 
Zip Code 
Phone Number 
Next Payment Due:
When will you be making payment?

If you have any additional mortgages on this property please continue.

yes no  (Please supply us with the information even if you have a zero balance on the account)
(Name of Bank/Mortgage Company) 
Loan No.: 
Address 
City 
State 
Zip Code 
Phone Number 
Next Payment Due:
When will you be making payment?

I/WE PAY CONDOMINIUM AND/OR HOMEOWNERS ASSOCIATION DUES TO THE FOLLOWING COMPANY(IES) (Please provide Management Co., phone number & address) 

Management Company
Address 
City 
State 
Zip Code 
Phone Number 
Next Payment Due:
When will you be making payment?

I/We will be in Naples, Florida for the closing. Yes  No 
If no, please overnight the documents to: Address
City 
State 
Zip Code 
Phone Number 

Please provide YOUR day-time phone number(s): 
Fax 
Other (Cell, Pager, etc.)

Additional Comments:

The OFFICES OF DUNN TITLE COMPANY, 801 Anchor Rode, Suite201, Naples, Fl. 34103, its agents and assigns, ("Agent"), are hereby authorized to obtain information concerning the above loans and the involved lenders or lessees, their successors, any request of my/our agent, including forwarding loan documents and Final Satisfaction of Mortgage to my/our agent.

(check here) I/We agree with the above.

 I/we confirm our social security numbers and address are correct as set forth in this document. Disclaimer : By submitting this electronic form, I, do hereby certify that the above information is true and accurate, to the best of my knowledge. Submitting this information represents your signature.

(check here) I/We agree with the above.