Old Republic Title Holding Company



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Escrow and Title Fee Request Form

Complete top portion and e-mail to Escrow Officer:

|Transaction Type: |Sale: | |Loan: | |Sale Price: | |

|Property Address: | |Loan Amount: |

|Borrower’s Names as they will appear on loan docs: |1st: | |

| |2nd: | |

| |Endorsements Required: |

|Estimated Closing Date: | | | |

| |Title Insurance for 2nd loan? | |

Do borrowers hold title in a trust? If so:

Title to stay in trust: _____ Deed required to individual borrowers: _____

Are additional borrowers being added to title?

|Names of additional borrowers: | |

Are any borrowers being taken off title?

|Names of borrowers deeding out of title: | |

Escrow to complete and return by e-mail:

|FEES |AMOUNTS |WHO PAYS IF BY |

| | |LOCAL CUSTOM? |

|Title Services & Lender’s Title Insurance: | | |

| Escrow Fee | | |

| Loan Tie-In Fee | | |

| Lender’s Premium: 1st loan | | |

| 2nd loan | | |

| Endorsements | | |

| Document Preparation | | |

| Notary Fees | | |

| Other | | |

| | | |

|Owner’s Title Insurance: | | |

| | | |

|Government Recordings Charges | | |

| | | |

|Transfer Taxes: | | |

| County: | | |

| City: | | |

Based on the information provided herein, the above fees are accurate for the transaction described above unless pertinent information is provided or if information given above changes after the date the fee information is provided:

_____________________________________ E-Mail address for docs:

Escrow Officer _______________________________________

Phone: _________________________________

Date: _______________________________ Fax: ___________________________________

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