Disclosure Statement Template: Controlled Business Arrangement (By A Producer Of Title Insurance Business Or Associate Thereof) printable pdf download

DISCLOSURE STATEMENT

CONTROLLED BUSINESS ARRANGEMENT

(By a Producer of Title Insurance Business or Associate thereof)

This Disclosure is made to: (Check one or both) _______ Seller/Owner _______Buyer

Seller(s)/Owner(s)

________________________________________________________

Buyer(s)

________________________________________________________

Regarding the Property Located at: __________________________________________________

__________________________________________________

For Title Insurance Company, Title Insurance Agent, and/or Escrow Agent:

(Company Name) _________________________________________________________________

In connection with the property described above, the undersigned has recommended, or is about to

recommend, the above named title insurance company, title agent, and/or escrow agent to the above named

party(ies) to provide title insurance and/or escrow services.

The undersigned producer has a financial interest in the above named company/business, or is an

associate of the party or entity which has said financial interest and therefore, makes, or has made, the following

estimate of the fees and charges that are known and which will be made in

connection with the recommended title and/or escrow services.

Only those charges which may be paid by the party(ies) to whom this disclosure is made, are (were)

disclosed herein. If there are additional parties who choose to utilize services from the above named

company/business, there may be additional charges for those services.

* Owner's Title Policy:

$____________________

* Mortgage Title Policy:

$____________________

Escrow or Closing Fee:

$____________________

Other Fees:__________

$____________________

____________________

$____________________

Total Estimated Charges:

$____________________

These estimated figures include all charges/services such as title search, title examination, title

insurance premiums, and final issuance of Policy(ies). These estimates may be revised if any unusual

circumstances occur, unusual risks are "insured over", and/or lenders require special

endorsements which extends their coverage.

You are not required to use __________________ (name of provider) as a condition for, settlement of

your loan on, or purchase, sale, or refinance of, the subject property. There are frequently other settlement

service providers available with similar services. You are free to shop around to determine that you are receiving

the best services and the best rate for these services.

The undersigned does hereby certify that the above disclosure was made to the above named party(ies) on

___________________________________.

Signature of Producer: ________________________________________ Date: _________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

ACKNOWLEDGMENT

I/we have read this disclosure form and understand that __________________ (referring party) is referring me/us

to purchase the above described settlement services from _____________________ (provider receiving referral)

and may receive a financial or other benefit as a result of this referral.

Seller/Owner:

_____________________________________________ Date:_________________________

_____________________________________________ Date: _________________________

Buyer:

_____________________________________________ Date: _________________________

(NOTE: PURSUANT TO SECTION 18.(b) OF THE TITLE INSURANCE ACT, THE TITLE INSURANCE COMPANY,

INDEPENDENT ESCROWEE,

OR TITLE INSURANCE AGENT SHALL MAINTAIN THIS DISCLOSURE FORM FOR A PERIOD OF 3 YEARS.)

DSI/4/98

Disclosure Statement Template: Controlled Business Arrangement (By A Producer Of Title Insurance Business Or Associate Thereof)

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