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EXHIBIT A

MAJOR STRUCTURAL DEFECT QUESTIONNAIRE FOR HOME OWNERS

Instructions:

PLEASE PRINT CLEARLY IN INK. It is important that you answer every question and enter all the information requested in this questionnaire so that we can process your claim. If an answer to a question is not known or the information requested is not readily available, do not leave the space blank as this will only delay the processing of your claim. If the answer to a question is not known, please indicate "UNKNOWN" in the blank space. If the information requested is not readily available, please provide a brief statement to that |{ and indicate where or from whom such information can be obtained. If you need additional space, please use the back side of the last page or attach additional pages to the last page with a reference number indicating which question the information is intended to answer. All information submitted on any back page or additional pages shall be deemed incorporated by reference herein as if fully set forth on this questionnaire. You must swear in the presence of a notary public to the truth and completeness of all information you provide in support of your claim, as provided on the last page of this questionnaire.

Name of Home Owner(s): _______________________________________________________________________________________

Address of Property: ___________________________________________________________________________________________

_____________________________________________________________________________________________________________

HOW Enrollment Number (see home owner certificate): _______________________________________________________________

Mailing Address, if different: _____________________________________________________________________________________

1) Daytime phone number: (_____ ) -___________________________ (_____ ) - _______________________________

Co-owner

2) Evening phone number: (_____ ) -___________________________ (_____ ) - _______________________________

Co-owner

3) Your Property Insurance Carrier: ______________________________________________________________________________

__________________________________________________________________________________________________________

Agent's Name: _______________________________________________ Phone Number: (_____ ) -_____________________

Policy Number: ____________________________________________________________________________________________

4) Date home was purchased: ___________________________________________________________________________________

Mortgagee or lienholder: ____________________________________________________________________________________

5) Type of loan: ...........FHA ...............VA ...............CONVENTIONAL (please circle one)

FHA or VA Case Number (if applicable): ____________________________________________________

6) Did the builder provide any of the following services: (check all applicable)

______landscaping ______decks ______patios ______pool ______spa ______septic

7) During original construction, did you or anyone other than the builder perform any work? Yes_____ No_____

If yes, please explain: _______________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

8) Were any inspections done prior to your purchase of the home? Yes ______ No _____

If yes, please indicate who performed the inspections and when they were performed: _____________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

9) Please describe the home and the property on which it is situated (check all applicable):

_____frame _____stucco _____brick _____stone _____one-story _____two-story


REPORT TO HOME OWNERS - Page 11

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