document.write('<table border=0 cellpadding=0 cellspacing=0 width=301 height=178> <tr> <td width=123 valign=top align=right><b>Property State:*</b><br></td> <td width=5 rowspan=5><img src="http://lowermybills.com/images/affiliate_banners/spacer.gif" width=5 height=1></td> ');

document.write('<td width=173 valign=top align=left> <select name="propertyStateCode" size="1"> <option value="" selected>Select One <option value="AL">Alabama <option value="AK">Alaska <option value="AZ">Arizona <option value="AR">Arkansas <option value="CA">California ');

document.write('<option value="CO">Colorado <option value="CT">Connecticut <option value="DE">Delaware <option value="DC">District of Columbia <option value="FL">Florida <option value="GA">Georgia <option value="HI">Hawaii <option value="ID">Idaho <option value="IL">Illinois ');

document.write('<option value="IN">Indiana <option value="IA">Iowa <option value="KS">Kansas <option value="KY">Kentucky <option value="LA">Louisiana <option value="ME">Maine <option value="MD">Maryland <option value="MA">Massachusetts <option value="MI">Michigan ');

document.write('<option value="MN">Minnesota <option value="MS">Mississippi <option value="MO">Missouri <option value="MT">Montana <option value="NE">Nebraska <option value="NV">Nevada <option value="NH">New Hampshire <option value="NJ">New Jersey <option value="NM">New Mexico ');

document.write('<option value="NY">New York <option value="NC">North Carolina <option value="ND">North Dakota <option value="OH">Ohio <option value="OK">Oklahoma <option value="OR">Oregon <option value="PA">Pennsylvania <option value="RI">Rhode Island <option value="SC">South Carolina ');

document.write('<option value="SD">South Dakota <option value="TN">Tennessee <option value="TX">Texas <option value="UT">Utah <option value="VT">Vermont <option value="VA">Virginia <option value="WA">Washington <option value="WV">West Virginia <option value="WI">Wisconsin ');

document.write('<option value="WY">Wyoming </select> </td> </tr> <tr> <td width=123 valign=top align=right><b>Property Description:</b><br></td> <td width=173 valign=middle align=left> <select name="propertyDesc" size="1" > <option value="0" selected>Single Family ');

document.write('<option value="1">Multi-Family <option value="2">Condominium <option value="3">Townhouse <option value="5">Mobile Home <option value="6">Manufactured Home </select> </td> </tr> <tr> <td width=123 valign=top align=right><b>Select Your<br>Credit Profile</b><br></td> ');

document.write('<td width=173 valign=top align=left> <table border=0 width=100% cellpadding=0 cellspacing=0> <tr> <td width=50% valign=top> <label><input type="radio" name="credit_profile" value="0">Excellent</label><br> <label><input type="radio" name="credit_profile" value="2">Fair</label><br> </td> ');

document.write('<td width=50% valign=top> <label><input type="radio" name="credit_profile" value="1" checked>Good</label><br> <label><input type="radio" name="credit_profile" value="3">Poor</label><br> </td> </tr> </table> </td> </tr> <tr> <td width=123 valign=top align=right><b>Type of Loan:</b><br></td> ');

document.write('<td width=173 valign=top align=left> <select name="typeOfLoan" size="1"> <option value="" selected>Select One <option value="LRE">Home Refinance <option value="LHP">Home Purchase <option value="LHE">Home Equity <option value="LDC">Debt Consolidation </select> </td> </tr> ');

document.write('<tr> <td width=301 colspan=3 valign=top align=center><input type="image" src="http://lowermybills.com/images/affiliate_banners/lmb_lre_ULFManlyMap_Affiliate_submit.gif" value="Submit" alt="Submit" border=0 hspace=0 vspace=5><br> </td> </tr> </table>');
