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2. Requester Name*
3. Requester Phone Number*

7. Seller's Information

9. Sellers First Name*
10. Sellers Last Name*
12. Email Address
14. Property Address*
16. City*
17. State*
18. Zip Code
20. Phone Number*
21. Fax Number
23. Closing Date*
    Closing Date

27. Sellers Attorney's Information

29. Sellers Attorney*
30. Sellers Attorney Email Address*
32. Sellers Attorney Phone Number*
33. Sellers Attorney Fax Number

37. Buyer's Information

39. Buyer's First Name
40. Buyer's Last Name*
42. Buyer's Email Address
44. Buyer's Address

    Enter Buyer's address if different from property address.

46. Buyer's City
47. Buyer's State
48. Buyer's Zip Code
50. Buyer's Phone Number

54. Buyer's Attorney Information

56. Buyer's Attorney*
57. Buyer's Attorney Email Address*
59. Buyer's Attorney Phone Number*
60. Buyer's Attorney Fax Number*

64. For Official Use Only

66. Account Number
67. Read Date
68. Reading
70. LBTR Date
71. LBTR
72. Days in Cycle
73. Prior Account Balance
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75. 1. Receive an email copy of this form.
76. Email address

    This field is not part of the form submission.

77. Submit Submit and Print

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