LICENSE VERIFICATION
Are you a Licensed Real Estate Agent? Yes No If yes, what State(s) / Country are you licensed in?

VERIFICATION OF YOUR ROLE - CHOOSE ONE

1. Principal Owner - Non Participating   You are the owner of record. You are not exclusively restricted to working with only one agent. If you are a licensed real estate agent, you are able to pay a earned commission as strictly a Principal Seller - with no requirement of participating in commissions. 2. Principal Owner - Participating You are the owner of record. As a licensee, you feel compelled to make it a requirement that you must participate in commissions. 3. Listing Agent or Licensed Owner's Representative You have completely read and fully understand The Way We Work . Therefore, you understand that we must be under written agreement with a brokerage firm prior to the presentation of their properties to our buyers and that this agreement is not a listing broker's commonly used "buyer registration agreement". Further, you are a licensed real estate agent who has full control & direct personal contact with your seller. 4. Other (Explain)

CONTACT INFORMATION

Your Valid Email Address (Required) Name & Title Company Mailing Address City City  State, Zip Code State   Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Puerto Rico Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington (state) Washington D.C. West Virginia Wisconsin Wyoming      Zip  Office Phone  Ext. Cellular / Mobile Phone Pager Number Home Phone Fax Number Your Home Page (if any)

ASSISTED LIVING PROPERTY YOU ARE SELLING

Name, Bed Name of Property         # of Beds    Address, Zip    Zip  City, County City     County  State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Puerto Rico Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington (state) Washington D.C. West Virginia Wisconsin Wyoming               Part of the State Central Northern Northwestern Northeastern Northcentral Southern Southwestern Southeastern Southcentral Eastern Eastcentral Western Westcentral Type & Ownership Assisted Living Facility Personal Senior Care Home Residential Senior Care Home Special Care Residence Retirement Community Senior Apartments Alzheimers / Dementia Care Personal Care Center Senior Care Residence Senior Center Skilled Nursing Facility       Corporation Partnership LLC Sole Proprietor Family Occupancy The property is currently running at  occupancy Income & Expenses 2000 2001 2002 2003 YTD Gross Income Less Expenses Net Operating Income Land Acrage, Tenure  Acres          Fee or Leased Land?  Fee Leased Asking Price, Appraisal Price      Appraised for  on  Owner Financing Are you offering any Owner-Financing? Yes No Owner will carry    for    Years at  interest. Existing Financing Original Loan       Non-Recourse?  Non-Recourse Recourse Current Loan Balance    Interest Rate   Amortized Over    Years.       Term: Due in   Years Annual Debt Service Payment   Annual Cash Flow   Cash on Cash Return   Price to Buyer: Cash over Mortgage   Assumable? YES   NO   Assumption fee is   Yield Maintenance / Prepayment Penalty? YES   NO Prepayment Penalty fee  Age, Condition When was the property built?    How would you best describe your property?         Value added through redevelopment, rehab, management       turnaround, releasing, expansion or retrofitting         Leased Up and Turnkey Remarks & Comments Commission Paid Seller is paying a brokerage commission of   of Sales Price

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