Empire Loss Mitigation



	Please Fill out this form to the best of your knowledge so that we may make a timely and accurate offer to you. All fields marked with a * are required.

		Your Information First Name Last Name Phone Email Property Information Property Address City State Zip Owner of Record Mailing Address Mailing Addres (If Different) City State Zip Please give a description of your situation. How did you end up where you are and what your plans for the home are: Property Information Beds: Baths: Square Feet Year Built Style Garage Estimated Value (Be Realistic) Has this property been listed with a Real Estate Agent? Mortgage Information First Mortgage Name of Company Balance Owed How far behind are you? Second Mortgage Name of Company Balance Owed How far behind are you?


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