Free Escrow Form

Escrow No.________

Date______________



STATEMENT OF:___________________________



                                      DEBITS        CREDITS

Deposits___________________________________________________

   Loan Proceeds___________________________________________

Demand for Deed and/or Note________________________________

Interest___________________________________________________

Prepayment Bonus___________________________________________

Forwarding Fee_____________________________________________

___________________________________________________________

Pro  Taxes_________________________________________________

Rata Insurance_____________________________________________

Commission_________________________________________________

___________________________________________________________

___________________________________________________________

Mechanic's Lien Search_____________________________________

Title Company's Charge_____________________________________

Reconveyance Fee___________________________________________

Recording Deed of Trust____________________________________

Recording Reconveyance_____________________________________

Recording Deed_____________________________________________

___________________________________________________________

___________________________________________________________

Taxes______________________________________________________

Special Assessments________________________________________

Insurance__________________________________________________

___________________________________________________________

Tax and Assessment Service_________________________________

Impounds___________________________________________________

Fee for Drawing Documents__________________________________

Credit Report______________________________________________

Appraisal Fee______________________________________________

Advance Reconveyance Fee___________________________________

Office Charge and Inspection Fee___________________________

___________________________________________________________

Deposited to the account of________________________________

Check Herewith_____________________________________________

   Balance due ____________________________________________
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