PURCHASE/LEASE REQUEST FORM **** ALL INFORMATION WILL REMAIN CONFIDENTIAL **** CONTACT  INFORMATION Submitter's Name Mailing Address City State Zip Code State AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MA MD MI MN MS MO MT NE NV NC NH NJ NM NY ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY   Phone: Cell: Fax: Email: * How did you hear about us? [Choose] The Journal - Classifieds The Journal - Web Directory The Journal - Online Jeff. Health Care Foundation - 5K Run Jeff. Health Care Foundation - Golf The Buyer's Guide - Newspaper The Buyer's Guide - Online Valpak You received a letter from us Google Search Yahoo! Search Yahoo! Local's Search From a Friend! Pick up our Business Card Posted Sign Other PROPERTY  INTEREST DESCRIPTION County? Town/City? Subdivision? City/Rural? Currently Rent of Own? [Choose] Rent Own Looking to Buy or Lease [Choose] Buy Lease Purchase Do you have pets? Special Needs? Style of Home [Choose] A-Frame Bungalow Cape Cod Ranch Raised Ranch Split-Level Split-Foyer Colonial Victorian Single-Wide Mobile Double-Wide Mobile Other # of Bedrooms [Choose] 1 2 3 4 5 6+ # of Bathrooms [Choose] 1 1.5 2 2.5+   Square footage [Choose] N/A < 800 Sq Ft. 800 - 1000 Sq. Ft. 1000 - 1250 Sq. Ft. 1250 - 1500 Sq. Ft. 1500 - 1750 Sq. Ft. 1750 - 2000 Sq. Ft. 2000 - 2250 Sq. Ft. 2250 - 2500 Sq. Ft. 2500 - 3000 Sq. Ft. 3000 - 4000 Sq. Ft. 4000+ Sq. Ft.   Foundation [Choose] Basement - Block Basement - Poured Crawl - Block Crawl - Poured Slab Other   Garage [Choose] N/A 1 Car 1.5 Car 2 Car 2.5+ Car   Lot size [Choose] N/A .25 acre .25 - .5 acre .5 - .75 acre .75 - 1 acre 1 - 1.5 acres 1.5 - 2 acres 2 - 3 acres 3 - 4 acres 4 - 5 acres 5 - 7 acres 7 - 10 acres 10+ acres MORTGAGE/LEASE INFORMATION Need a lender?  Yes    No   If no, are you pre-qualified?  Yes    No   How much can you afford? [Choose] Below $40,000 $40,000-$60,000 $60,000-$80,000 $80,000-$100,000 $100,000-$125,000 $125,000-$150,000 $150,000-$175,000 $175,000-$200,000 $200,000-$250,000 $250,000-$300,000 $300,000+ Max Monthly Payment [Choose] Below $650 $650 - $699 $700 - $799 $800 - $899 $900 - $999 $1,000 - $1,149 $1,200 - $1,349 $1,350 - $1,499 $1,500 - $1,749 $1,750 - $1,899 $1,900 - $2,199 $2,200 - $2,499 $2,500 + Amt you can put down? [Choose] Below $4,999 $5,000-$9,999 $10,000-$14,999 $15,000-$19,999 $20,000-$24,999 $25,000-$29,999 $30,000-$49,999 $50,000-$74,999 $75,000 + Date you can buy?  *Required Field       Please Click Only Once.