Selling Broker Settlement Information Request

Please fill in all required and applicable fields on this secured form.

File No.

Property Address

Name

Contact Information:

Brokerage Company Name

Brokerage Company Address

Brokerage Company State License ID

Agent's Name

Agent's State License ID

Agent's E-Mail

Agent's Phone Number

Commission Information:

Total Commission Amount

Selling Agent % / $

General Information:

Do you have an administrative/flat fee?

Yes
No

If yes, please list the amount here

Will there be any reimbursements due to you at closing?

Yes
No

If "Yes", please specify said reimbursement(s) here

Are there any credits to Purchaser or Seller from you at closing?

Yes
No

If "Yes", please specify said credit(s) here and upload broker letter below

Lender Information:

Please provide us with the Purchaser's lender name and contact information (if applicable):

Company Name

Loan Officer

Loan Officer's Contact Phone Number

Loan Officer's E-mail Address

If the purchaser is paying for the following, please provide the information requested below:

Termite Company Name & Phone Number

Well Report Company Name & Phone Number

Septic Report Company Name & Phone Number

Home Warranty

Yes
No

If the purchaser is obtaining a home warranty at closing, please PROVIDE A COPY OF THE INVOICE prior to closing. You may attach it below.

If you are providing a commission credit, PLEASE PROVIDE A BROKER LETTER. You may attach it below.

Select files to attach

Size limit for each file is 100 MB

General Comments