Copyright ©2005 Greater Illinois Title Company. All Rights Reserved. http://gitc.com/forms/
Compliments of Greater Illinois Title Company; for Internal and External Use.
Universal Doc Ref: GP_IEF0006-20050803-R1-1
INFORMATION SHEET
FOR USE BY INDIVIDUAL OR HUSBAND AND WIFE
Order Number: ________________________________ Date: ___________________________________________
The information contained on this form is confidential and for the use of Greater Illinois Title Company and the policy
underwriter. It will be used solely for the purpose of determining whether certain matters of record affect the title to the premises
be
ing insured under the above order number or whether these matters relate to the other persons with like or similar names. Please
t
ype or print. NOTE: If additional space is required, attach on separate 8-1/2” x 11” sheet with a minimum of 1/2” clean margin on
all
sides.
Name of Parties and Social Security Number(s)
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________________________________________
Name
__
________________________________________
Social Security Number
_
_
________________________________________
Date
_
_
________________________________________
N
ame
__
________________________________________
Social Security Number
_
_
________________________________________
Date
I
f
Husband and Wife, Maiden Name ___________________________ and date of Marriage:_____________________________
Pr
esent Address:__________________________________________________________________________________________
O
ther Address(es) that you either own, have owned, or resided at since 1985:
__
_____________________________________________________________________________________________________
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_____________________________________________________________________________________________________
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_____________________________________________________________________________________________________
Na
me and Address of present employer:
__
_____________________________________________________________________________________________________
Name(s) and address(es) of other employer(s) since 1985:
_
_
_____________________________________________________________________________________________________
__
_____________________________________________________________________________________________________
Li
st below any divorce proceedings, name changes or uses of an alias, bankruptcy proceedings, or judgments and liens that affect
th
e parties:
__
_____________________________________________________________________________________________________
__
_____________________________________________________________________________________________________
I/We the u
ndersigned, hereby state that there are no outstanding judgments or liens nor have I/We filed any recent bankruptcy
p
roceedings other than the above, if any. I/We agree to hold Policy Issuing Agent and Chicago Title Insurance Company harmless
fro
m any claims which may result therefrom. I/We give this information to induce Policy Issuing agent and Chicago Title
I
nsurance Company to issue its title policy clear of any judgments, liens or bankruptcies affecting title.
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____________________________________________
Signature
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___________________________________________
Signature
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