Please print this form, supply the requested information, sign, date,and return to the address listed below.
CLIENT CONFIDENTIALITY RELEASE AUTHORIZATION

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: ____________________________________

The following person(s) is (are) the LEGAL BORROWER(s) on the property address listed below.

Name #1: ___________________________________ Social Security Number #1: _________________________

Name #2: ___________________________________ Social Security Number #2: _________________________

Property Address: ____________________________________________________________________________

City: _____________________________________ State: ______________ Zip Code: _____________________

This property is held as:  individual  trust  corporate  community property
(check one only)                  husband and wife as joint tenants  husband and wife as community property

This property was purchased on (date): ____________________________________________________________

Type of loan:  Conventional  VA  FHA  Other (please specify): ___________________________________

I(we) are in default on the  1st trust deed  2nd trust deed  3rd trust deed  other: _______________________

I(we) give the lender, servicer, and/or insurer of the mortgage loan referenced above permission to speak with and disclose financial records 
to Reinstatement Services, Inc. I(we) give Reinstatement Services, Inc. permission to speak with the lender listed above on my (our) behalf. 
I(we) understand that the service provided by Reinstatement Services, Inc. is by no means a Guarantee that the Lender will accept the relief 
measure being offered. As such, Reinstatement Services, Inc. accepts no liability for actions taken by the lender.


____________________________________________    ____________________________________________
Borrower(s) Signature     Type or Print Name    Borrower(s) Signature     Type or Print Name

____________________________________________    ____________________________________________
Date                                            Date

Reinstatement Services Inc.
Attn: Client Relations Department
202 N. Curry Street, Suite 100, Carson City, NV  89703  
Ph (775) 883-1874
© 2007 by Reinstatement Services, Inc.      Form 813-OL