Confidential Statement Of Information
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2CONFIDENTIAL STATEMENT OF INFORMATION
This statement is to be signed personally by each party to the transaction and by both spouses/partners, if married/registered (Section
1 is to be completed by the husband/partner, and Section 2 by the wife/partner). This information is necessary because we have been asked
to insure a transaction involving real property in which you are interested. In that regard, we may encounter judgments, bankruptcies,
dissolutions and liens against persons with the same or similar name as yours.
Property Address of Transaction:
Order Number
Number & Street
City, State & Zip
Vacant Land:
Is any portion of the new loan
Improvements:
Is Property:
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Single Family
to be used for improvements?
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Multiple Residence
Owner Occupied
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Yes
No
Yes
No
Commercial
Tenant Occupied
1.
Name:
First
Middle (If None, write None)
Last
Social Security No.
Driver’s License No.
Date of Birth
Place of Birth
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Have you ever been issued, or used, any other Social Security Number?
Yes
No If yes, what number did you use?
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Status:
Single
Married*
Divorced
Widow/Widower
Registered Domestic Partner
Mark One:
Male
Female
*Married or Registered On:
At
(Date)
(City, County, State)
*If married, spouse’s name
*Spouse’s name prior to marriage
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* Have you ever used another name
Yes
No - provide all names
State resident since (date)
OCCUPATIONS LAST TEN YEARS
Occupation
Firm Name
Address
No. Years
Occupation
Firm Name
Address
No. Years
RESIDENCES LAST TEN YEARS
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Own
Rent
Number and Street
City and State
From (date)
To (date)
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Own
Rent
Number and Street
City and State
From (date)
To (date)
FORMER MARRIAGES/REGISTERED DOMESTIC PARTNERSHIP
If no former marriage, write “none”, otherwise complete the following:
Name of former spouse/partner:
Social Security No.
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Deceased:
Dissolution:
Date:
Where:
First and last name(s) of children from this marriage
Social Security No.
Name of former spouse/partner:
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Deceased:
Dissolution :
Date:
Where:
First and last name(s) of children from this marriage
2.
(Spouse’s/Partner’s Name):
First
Middle (If None, write None)
Last
Social Security No.
Driver’s License No.
Date of Birth
Place of Birth
□
□
Have you ever been issued, or used, any other Social Security Number?
Yes
No
If yes, what number did you use?
□
□
□
□
□
□
□
Status:
Single
Married*
Divorced
Widow/Widower
Registered Domestic Partner
Mark One:
Male
Female
*Married or Registered On:
At
(Date)
(City, County, State)
*If married, spouse’s name
*Spouse’s name prior to marriage
□
□
* Have you ever used another name
Yes
No - provide all names
State resident since (date)
OCCUPATIONS LAST TEN YEARS
Occupation
Firm Name
Address
No. Years
Occupation
Firm Name
Address
No. Years
RESIDENCES LAST TEN YEARS
□
□
Own
Rent
Number and Street
City and State
From (date)
To (date)
□
□
Own
Rent
Number and Street
City and State
From (date)
To (date)
FORMER MARRIAGES/REGISTERED DOMESTIC PARTNERSHIP
If no former marriage, write “none”, otherwise complete the following:
Name of former spouse/partner:
Social Security No.
□
□
Deceased:
Dissolution :
Date:
Where:
First and last name(s) of children from this marriage
Name of former spouse/partner:
Social Security No.
□
□
Deceased:
Dissolution :
Date:
Where:
First and last name(s) of children from this marriage
I declare, under penalty of perjury, that the foregoing is true and correct.
Signature:
Date:
Home Phone:
Business Phone:
Signature:
Date:
Home Phone:
Business Phone:
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