Borrower Information Sheet & Authorization

Borrower #1 Name:

Social Security #:

Borrower #2 Name:

Social Security #:

Current Address:

Address of Property being Financed:

Your Telephone No.:

Home Owners Insurance Information

Contact Person:

Agent:

Address:

Telephone:

Fax:

Current Mortgage Information

Lender #1 Name:

Address:

Telephone:

Account No.:

Lender #2 Name:

Address:

Telephone:

To whom it may concern:

Please freeze, block and close the above account(s). Also, please issue a payoff statement, any other pertinent information, and when paid in full, a discharge of mortgage to Lieberman Law Office, P.C.
36 Washington Street, Wellesley, MA 02481

I/We hereby authorize this release of information to Lieberman Law Office.

INITIAL HERE Borrower #1 (please accept this as my digital signature)

INITIAL HERE Borrower #2 (please accept this as my digital signature)

Lieberman Law Office PC • 36 Washington Street, Suite 280 Wellesley, MA 02481
P 781.235.3200 • F: 781.235.3700