Real Estate Owner Identification Form

REAL ESTATE OWNER IDENTIFICATION FORM

Property Identification

Property Address:

Parcel / APN:    County:

Owner(s) of Record

Owner Full Legal Name:

Individual    Corporation    Limited Liability Company (LLC)    Trust    Other:

Ownership Interest (e.g., Fee Simple, Leasehold):    Percentage Owned:

Date of Acquisition:    Recorded Deed Reference (Book/Page or Instrument No.):

Entity / Beneficial Owner Details (if applicable)

State or Jurisdiction of Formation:    Registration Number:

Liens, Encumbrances, Litigation

Are there any outstanding mortgages, liens, or recorded encumbrances affecting title?   Yes    No

Is any litigation, claim, or notice pending or threatened with respect to the property?   Yes    No

Property Condition Disclosures

Lead-based paint disclosure applicable (if constructed prior to applicable cutoff year):   Yes    No

Known mold, water intrusion, or unresolved moisture issues:   Yes    No

Prior material structural damage or major repairs (fire, flood, sinkhole, etc.):   Yes    No

Certification and Authorization

I certify, under penalty of law, that I am the owner of record or an authorized representative of the owner identified above and that the information provided on this form is true, correct and complete to the best of my knowledge. I further certify that I have the full authority to furnish this information and to permit the release of ownership and title information to third parties for legitimate purposes related to the administration, sale, refinancing, or management of the property.

I agree to notify any requesting party of material changes to the information provided herein. I acknowledge that providing false or misleading information may subject me to civil liability and penalties under applicable law. I authorize any public recorder, title company, or lienholder to provide copies of documents necessary to verify the statements contained in this form.

Governing Law: This form, and any dispute arising from the information herein, shall be governed by the laws of the state in which the property is located, without regard to conflict of laws principles. This document constitutes the entire written owner identification and supersedes any prior written statements delivered for the property identified above.

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