Please Print and Mail to:
Rick O'Hara & Associates · 4165 E. Thousand Oaks Blvd. Suite 250 
Westlake Village, California  91362 · Phone: (805) 379-3911 Fax: (805) 379-1845

LENDER INFORMATION & INSTRUCTIONS

Lender Account #______________

Name________________________________________________________

Name________________________________________________________

Legal Vesting (Note:  If legal vesting is a Trust, we must have a copy of the
Trust Agreement for our files.) 
_____________________________________________________________
_____________________________________________________________

Tax Identification Number:_____________________________________

Mailing Address for Correspondence
_____________________________________________________________
_____________________________________________________________

Make Payments on the Above Referenced Account Payable as Follows:
_____________________________________________________________
_____________________________________________________________

Mailing Address for Payments
_____________________________________________________________
_____________________________________________________________

Phone Number (Home):_________________________________________
Phone Number (Work):_________________________________________
Fax Number:_________________________________________________
E-Mail Address:_______________________________________________

You have permission to give information about my account to:
_____________________________________________________________

Please do NOT give information about my account to:
_____________________________________________________________

Special Instructions:
_____________________________________________________________
_____________________________________________________________

Lender Signature_________________________  Date:_______________

Lender Signature_________________________  Date:_______________