Statement of Information
CONFIDENTIAL - TO BE USED ONLY IN CONNECTION WITH ESCROW NO: ______________
NOTE: This form is very important. It is needed to verify your identity and to eliminate judgments and liens against people with similar names.
THE STREET ADDRESS of the property in this transaction is: (If none, please leave blank)
ADDRESS CITY and STATE
1. Improvements: Single Residence Multiple Residence Commercial Vacant Land
2. Occupied by: Owner Tenants 3. ANY CONSTRUCTION WITHIN THE LAST 6 MONTHS? YES NO
4.
IF YES to No. 3, STATE NATURE WORK DONE:
PARTY 1 PARTY 2
First Middle Last First Middle Last
Former Last Name(s), if any Former Last Name(s), if any
Birthplace Birth Date Birthplace Birth Date
Social Security Number Driver’s License No. Social Security Number Driver’s License No.
I am single am married have a registered domestic partner I am single am married have a registered domestic partner
Current spouse or Registered Domestic Partner (Other Than Party 2): Current Spouse or Registered Domestic Partner (Other Than Party 1):
Name: Name:
Former spouse/domestic partner (if none – check this box ) : Former spouse/domestic partner (if none – check this box ):
Deceased Date: Where: Deceased Date: Where:
Divorce/Dissolution Date: Where: Divorce/Dissolution Date: Where:
Children from current and/or former marriages and/or domestic partnerships Children from current and/or former marriages and/or domestic partnerships
Child Name: DOB Child Name: DOB:
Child Name: DOB Child Name: DOB:
Marriage or Domestic Partnership Between Parties 1 and 2
Are Parties 1 and 2: Married? Date______________ Registered Domestic Partners? Date:______________
Party 1 – Occupations for the Last 10 Years (attach an additional page, if necessary)
Present Occupation Firm Name Address From To
Present Occupation Firm Name Address From To
Party 1 – Residences for the Last 10 Years (attach additional page, if necessary)
Number and Street City, State, Zip Code From To
Number and Street City, State, Zip Code From To
Party 2 – Occupations for the Last 10 Years (attach an additional page, if necessary)
Present Occupation Firm Name Address From To
Present Occupation Firm Name Address From To
Party 2 – Residences for the Last 10 Years (attach additional page, if necessary) (if same as Party 1, write “same”)
Number and Street City, State, Zip Code From To
Number and Street City, State, Zip Code From To
Have any of the above parties owned or operated a business? No Yes If yes, please list name(s):
I have never been adjudged, bankrupt nor are there any unsatisfied judgments or other matters pending against me which might affect my title to this
property except as follows:
The undersigned declare under penalty of perjury that the above information is true and correct (all parties must sign)
Home # Business # Home # Business #
Cell # E-Mail: Cell # E-Mail:
Party 1 Signature Date Party 2 Signature Date
Statement of Information. REV. 11/4/08