Date of Inquiry

MM-DD-YY

Consumer contact information

Name(s) (last, First)

Property Address (Street, City, State, Zip)

Contact Addess (if different from Property Address

Contact Phone Number

Additional Contact Phone Number

Transaction Information

Agent File Number / Policy Number

Property Type (Residential or Commercial) Transaction Type (purchase, Refi, REO, etc…)

Briefly describe the nature of the consumer’s inquiry including dates of any conversations, phone call and names (including title and company affiliation) of those with whom consumer has spoken

Indicate whether additional information or documentation is attached under separate cover

Advise consumer that this will be routed to Contact Name Contact Title

Name / Title of person Completing form

Management Review Name / Title