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:
Re-conveyance Fee:
Recording Deed of Trust:
Recording Re-conveyance:
Recording Deed:

Taxes:
Special Assessments:
Insurance:

Tax and Assessment Service:
Impounds:
Fee for Drawing Documents:
Credit Report:
Appraisal Fee:
Advance Re-conveyance Fee:
Office Charge and Inspection Fee:

Deposited to the account of:
Check Herewith:
   Balance due: