Please print this form, supply the requested information, sign, date,and return to the address listed below. GENERAL INFORMATION FORM
Client(s) Name: _____________________________________________________________________________ Mailing Address: ____________________________________________________________________________ City: ______________________________________ State: ______________ Zip Code: ___________________ Phone Number (Home): ______________________________ (Work): __________________________________ Servicer [Mortgage Co.] Name: ______________________________ Loan Number: _______________________ Mailing Address: ____________________________________________________________________________ City: ______________________________________ State: ______________ Zip Code: ____________________ Phone Number: ______________________________ Fax Number: ____________________________________ ____________________________________________ ____________________________________________ Borrower(s) Signature Type or Print Name Borrower(s) Signature Type or Print Name ____________________________________________ ____________________________________________ Date Date
If paying by cashier check, money order, or personal check be sure to enclose the correct service fee. Allow 14 days for processing personal checks. You may also pay by visiting our home at: http://www.reinstate.com/order.htm Remember, our service fee is priced per loan and applies to single family dwellings only. Reinstatement Services Inc. Attn: Client Relations Department 202 N. Curry St, Suite 100, Carson City, NV 89703 Ph (775) 883-1874 © 2007 by Reinstatement Services, Inc. Form 319-OL