Form T 00 – Fill Out and Use This PDF

VERIFICATION OF SERVICES RENDERED – Form T-00

INSTRUCTIONS

1.The Agent/Entity desiring to be paid shall complete Section 1, sign, date and deliver the form, together with a written itemized statement or invoice, when the work is performed or delivered.

2.The Agent/Underwriter issuing the policy shall complete Section 2.

3.The Agent/Underwriter paying for the work shall complete Section 3, sign, date and deliver a copy of the form to both the Agent/Entity being paid and the Agent/Underwriter issuing the policy.

4.All parties shall retain in their records a fully signed copy of this Form T-00 and a copy of the written itemized statement or invoice.

SECTION 1 – INFORMATION FROM AGENT/ENTITY REQUESTING PAYMENT

1. Service for which payment is requested:	 Furnishing Title Evidence
	 Title Examination
	 Closing the Transaction

Address of location where work was done for selected service(s):

_________________________________________________________

Order/File/GF# assigned to this order by Agent/Entity doing the work:

_________________________________________________________

2.AGREEMENT REGARDING PAYMENT FOR SERVICE: Percentage or amount of premium (remaining after remittance to Underwriter) agreed to be paid to the Agent/Entity doing the work:

____________________% or $_________________________

3.INFORMATION ABOUT AGENT/ENTITY DOING THE WORK:

Type of entity:  Texas Underwriter  Texas Title Agent

 Texas Attorney at Law or Texas PC organized to provide legal services

Name: ____________________________________

Address: __________________________________

City, State/ZIP ______________________________

Texas Department of Insurance Number or Texas State Bar #: _____________

Undersigned certifies that the service for which payment is requested was actually performed.

______________________________	Date: ____________________
Signature of Authorized Representative
for Agent/Entity Doing the Work

SECTION 2 – INFORMATION FROM AGENT/UNDERWRITER ISSUING THE POLICY

4. Date of Policy (ies): ____________County Code(s): ___________

Order/File/GF# assigned to this Policy (ies) by Issuing Agent/Underwriter: _________________

5.Issue Type:  Out-of-County (2) – Title Evidence from Texas Agent

Multi-County (1) – Title Evidence from Texas Agent

Best Evidence (0) – No title evidence from Texas Agent

6.Liability and Premium Amount(s):

Owner Title Policy (ies)	Liability: $_________	Premium: _________
Mortgagee Policy (ies)	Liability: $________	Premium: $_________
Endorsement(s)		$_________
Other		$_________
	TOTAL	$_________
Final amount remaining after remittance to the Underwriter:		$_________
Final amount paid to the Agent/Entity doing the work:		$_________

FORM T-00: Verification of Services Rendered

Sec. V

7.INFORMATION ABOUT AGENT/UNDERWRITER ISSUING POLICY: Name: ____________________________________

Address: __________________________________

City, State/ZIP ______________________________

Texas Department of Insurance Number: __________

SECTION 3 – INFORMATION FROM AGENT/UNDERWRITER PAYING FOR THE WORK

8.INFORMATION ABOUT AGENT/UNDERWRITER PAYING FOR THE WORK: Name: ____________________________________

Address: __________________________________

City, State/ZIP ______________________________

Texas Department of Insurance Number: __________

Order/File/GF# assigned to this order by Agent/Underwriter paying for the work ___________

Undersigned certifies that the above description of work performed is accurate and the final amount shown paid is correct.

______________________________	Date: __________________
Signature of Authorized Representative
for Agent/Underwriter Paying for the Work

FORM T-00: Verification of Services Rendered

Sec. V