Preferred RGS Title Location:

Are you a:

Borrower (1) Name:

*SSN#:

Borrower (2) Name:

*SSN#:

Office Phone :

Home Phone:

Fax:

Email:

Property Address:

City:

State:

Zip Code:

New Lender Company Name:

Loan Officer Name:

Loan Officer Phone:

Loan Officer Fax:

Loan Amount:

Loan (1) Lender Name:

Account Number::

Lender Street Address:

City:

State:

Lender Phone #:

Loan (2) Lender Name:

Account Number::

Lender Street Address:

City:

State:

Lender Phone #:

Is this a Home Equity Loan (HELOC)? :

   YES      NO:

Anticipated
Closing Date:

Special Requests:

* Optional Information
**If you do not receive a phone call from us please call your local RGS Office for confirmation.