A&J Title Insurance Application Amundson & Johnson, P.A. / A&J Abstract & Title 217 West James Street • P.O. Box 241 • Paynesville, MN 56362 209 Manitoba Street West • P.O. Box 536 • Spicer, MN 56288 PHONE: (320) 243-3878 • FAX: (320) 243-4956 Licensed Agent of Old Republic National Title Insurance Co. Application Date:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Anticipated Closing Date:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Applicant:First Name, Last Name or BusinessApplicant Address: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Applicant Phone NumberContactTRANSACTION DATAType of PolicyLendersOwnersContract Vendee'sLender and Owners CombinedMortgage AmountPurchase PriceType of TransactionPurchaseRefinance2nd MortgageLender and Owners CombinedProperty LocationProperty Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Proposed InsuredLenderBorrower/Buyer Name(s)Separate names with a comma.Borrower/Buyer Present Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Borrower/Buyer Marital StatusSingle, never marriedMarriedDomestic partnershipDivorcedWidowedSeparatedBorrower/Buyer Phone (Home)Borrower/Buyer Phone (Work)Borrower/Buyer Social Security NumberSellersSellers Name(s)Separate names with a comma.Sellers Marital StatusSingle, never marriedMarriedDomestic partnershipDivorcedWidowedSeparatedSellers Present Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Sellers Phone (Home)Sellers Phone (Work)Are You Working With a Realtor?YesNoAgent's NameAgent Phone NumberProperty InformationType of PropertyResidentialCommercialVacant LandExisting BuildingsAny New Construction or Remodeling Within the Last 120 Days?YesNoPremises Now Occupied By:OwnerTenantC.D. HolderTitle EvidenceAbstractYesNoRPAYesNoTorrens/Certificate No.Searches NeededSpecial Endorsements NeededOther InstructionsIn the event of cancellation of application, the applicant agrees to return to the company any commitments or policies issued by it and to pay said company its out-of-pocket expenses and a reasonable service charge for services rendered.CAPTCHA
