First Name   
                                           Last Name  
                                           Address      
                                           City State
                                           Daytime Contact Number (xxx-xxx-xxxx)

                                           Type of Foundation: Full Basement Partial Basement Crawl Space Slab Foundation Unsure or Unknown
                                           Garage Type:           No Garage 1 Car Garage 2 Car Garage 3 Car Garage 4 Car Garage or More 1 Car Carport 2 Car Carport 3 Car Carport
                                           Style of Home:         1 Story 1 1/2 Story 2 Story Bi-Level Tri-Level Quad-Level Uniplex Duplex 3 Unit 4 Unit Condo
                                           Condition of Home Very Poor Poor Fair Good Very Good Excellent Perfectly Maintained
                                           Number of Bedrooms
                                           Number of Bathrooms
                                           Total Square Footage
                                           Lot Size (if known)

                                           Tell us the features of your home: Explain the extra features of your home here.