Statement Of Information Form
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2STATEMENT OF INFORMATION
(For confidential use by the Title Company in searching the records in connection with the fie number shown below.)
Property Address:
File No.: ____________________
________________________________________________
Ref No.: ____________________
________________________________________________
In order to expedite the completion of your transaction we are requesting that you complete the following “statement of
Information” form. We are not unnecessarily interested in your personal affairs, however, we have been asked to insure
the title to real property in which you are interested and that requires a title search.
In searching your title we may encounter judgments, bankruptcies, divorces and/or income tax liens against persons with
the same or similar names to yours. Such matters cloud the title to your property unless eliminated. The information you
provide, and your spouse if you are married, can promptly eliminate all matters not directly affecting you or the property
being searched, avoid any delay in your transaction and provide you with the most efficient service possible.
Thank you for your cooperation in furnishing us with the necessary information and please be assured that your
information is confidential and used only for the purpose which we have stated.
Name: _______________________
___________________
_______________________
__________
US Residence since:
First
Middle – if none, indicate
Last
Year
Have you ever been known by any other name: No
Yes
If yes, indicate name: _____________________________________
Social Security Number: _______________________________
Driver License Number: ___________________________________
Date of Birth: _______________________________________
Location of Birth: ________________________________________
Spouse’s Name: _______________
___________________
_______________________
__________
US Residence since:
First
Middle – if none, indicate
Last
Year
Have you ever been known by any other name: No
Yes
If yes, indicate name: _____________________________________
Social Security Number: _______________________________
Driver License Number: ___________________________________
Date of Birth: _______________________________________
Location of Birth: ________________________________________
RESIDENCES LAST 10 YEARS
(list most recent first)
________________________________
____________________________________________________
___________________
Number and Street
City, State, Zip Code
From/To (Date)
________________________________
____________________________________________________
___________________
Number and Street
City, State, Zip Code
From/To (Date)
________________________________
____________________________________________________
___________________
Number and Street
City, State, Zip Code
From/To (Date)
(attach additional page, if necessary)
OCCUPATIONS
__________________
__________________________
_____________________________________
__________________
Occupation
Company Name
Address, City, State, Zip Code
No. Yrs/Mos
__________________
__________________________
_____________________________________
__________________
Spouse’s Occupation
Company Name
Address, City, State, Zip Code
No. Yrs/Mos
BUSINESS OWNED OR PARTNERSHIP AFFILIATIONS
__________________
__________________________
_____________________________________
__________________
Tax ID Number
Firm/Partnership Name
Address, City, State, Zip Code
No. Yrs/Mos
__________________
__________________________
_____________________________________
__________________
Tax ID Number
Firm/Partnership Name
Address, City, State, Zip Code
No. Yrs/Mos
(attach additional page, if necessary)
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