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1. Your Information
Enter your personal information here. Make sure to use current information so that we can contact you if necessary.
Ordering Party:
Company Name:
Address:
City:
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ZIP:
Phone:
FAX:
Contact Name:
E-Mail Address:
2. Preferences
Fill out the forms below to be in contact with a specific officer.
Preferred Escrow Officer:
Preferred Title Officer:
Preferred Sales Rep:
3. Transaction Info
Enter information about the loan or loans to be paid off in the transaction.
Transaction Type:
Sale
Refinance
Sale Amount:
Loan Amount:
Loan Type:
1st
2nd
Other
4. Buyer/Borrower Information
Enter information about the buyer. If there is only one buyer, leave the boxes for the second buyer blank.
Buyer #1 Name:
Buyer #1 SSN:
Buyer #2 Name:
Buyer #2 SSN:
5. Payoff Information
Enter information about the loan(s) used to buy or refinance the property.
Lender's Name:
Loan #:
Payoff Amount:
Lender's Name:
Loan #:
Payoff Amount:
6. Subject Property Information
Enter information about the property in question. Provide a mailing address for documents only if the mailing address is different from the property address.
Property Address:
Property City:
Property State:
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AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Property ZIP:
Mailing Address:
Mailing City:
Mailing State:
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AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
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NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
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WY
Mailing County
Apache
Cochise
Coconino
Gila
Graham
Greenlee
La Paz
Maricopa
Mohave
Navajo
Pima
Pinal
Santa Cruz
Yavapai
Yuma
Mailing ZIP:
7. Legal Description
Provide legal information regarding the property.
Lot:
Block
Tract:
Map Book:
Page:
Tax/APN:
Full Legal:
8. Title and Escrow Services Requested
Indicate what type of service you want, the type of Title Policy if applicable, and any special requests. If you want to work with certain people at Empire Title, you can enter their names in the Escrow Officer, Title Officer, and Sales Rep fields.
Owner's Policy Type:
Standard
ALTA Homeowner's
ALTA Extended
First Loan Policy Type:
ALTA
Expanded
Standard
Second Mortgage Order Type:
Standard
Liability Policy
Limited Report
Miscellaneous:
Trustee's Sale Guarantee
Litigation Guarantee
Condition of Title Report
Services Requested:
Title & Escrow
Title Only
Other
Special Instructions:
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