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| Your name |
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| Your email address |
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| Your home phone number |
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| Your day time phone number |
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| Best time to call |
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| Are you personally receiving the payments |
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| Note balance |
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| How secured |
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| Please describe the business |
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| How was the note originated |
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| Please describe the premises |
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| Interest rate |
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| When originated M D Y |
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| Down payment |
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| Payment amount |
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| When payments made |
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| Number of payments made |
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| Number of payments left |
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| Current |
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| Value of real estate if included |
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| Position of note |
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| Describe any other financing |
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| Please describe any balloon payments |
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| Borrowers credit if known |
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| Business City |
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| Business state |
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