Form Ds 1 – Fill Out and Use This PDF

FORM DS-1

DFI-Rev.05/01/97

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)

(Print Name(s))

Buyer(s)

(Print Name(s))

Regarding the Property located at:

Street

City

State

Zip Code

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

(Print Company Name) First American Title

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 estimates 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 First American Title 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 ____________________

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ACKNOWLEDGEMENT

I/we have read this disclosure form and understand that ____________________________________ (referring party) is referring me/us to purchase the above

described settlement services from First American Title and may receive a financial or other benefit as a result of this referral.

Seller/Owner:		Date:
		Date:
Buyer:		Date:
		Date:

(NOTE: PERSUANT 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.)

Disclosure Statement – Controlled Business Arrangement

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