Person Ordering Title Date Contact # Email Property Address Township County Parcel Number (if known) Owners of Record/Borrowers 1 Owners of Record/Borrowers 2 Mailing Address Phone #s Cell work Home Marital Status marriedseparateddivorced New Mortgage Amount $ New Mortgage Company Address Contact Person(s) loan originator phone fax processor phone fax Estimated Closing Date Time Place of Settlement Would you like KPSS to order the following? Tax cert yesno Water/Sewer Cert yesno 3407/5407 certificate yesno Mortgage payoff(s) yesno Payoff Information Company Name Address (if known) Account # Phone # Fax # Company Name Address (if known) Account # Phone # Fax # Misc. Comments/Requests