American Equities, Inc.

Brokers QUOTE REQUEST FORM

Date:
First Name:
Last Name:
Phone:
Email:
Address of Property:
Description of Property:
Any Other Details
About Property:
Instrument Used:
Position:
Collection Method:
If Service Agency
Name of Agency:
Date Sold:
Sale Price:
Estimated Current
Property Value (if known):
Down Payment:
Interest Rate
Current Balance:
Monthly Payment:
Number of
Payments Remaining:
Balloon Due Date:
Underlying Balance:
Person Submitting Request: Note Holder
Broker
How did you hear about AEI?
Comments:
(Please include any other information that would be helpful in assessing your contract)
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