To:
From:
(Entity Making Statement)
Property:
Date:
This is to give you notice that [referring party]
has a business relationship with [settlement services provider(s)]. [Describe the nature of the relationship between the referring
party and the provider(s), including percentage of ownership interest,
if applicable.] Because of this relationship, this referral may provide
[referring party] a financial or other benefit.
[A.] Set forth below is the estimated
charge or range of charges for the settlement services listed. You
are NOT required to use the listed provider(s) 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.
[provider and settlement
service]
[charge or range
of charges]
[B.] Set forth below is the estimated charge or range
of charges for the settlement services of an attorney, credit reporting
agency, or real estate appraiser that we, as your lender, will require
you to use, as a condition of your loan on this property, to represent
our interests in the transaction.
[provider
and settlement service]
[charge or range
of charges]
ACKNOWLEDGMENT
I/we have read this disclosure form, and understand that referring party is referring me/us to purchase the above-described
settlement service(s) and may receive a financial or other benefit
as the result of this referral.
Signature
[INSTRUCTIONS TO PREPARER:]
[Use paragraph A for referrals other than those by a lender to an
attorney, a credit reporting agency, or a real estate appraiser that
a lender is requiring a borrower to use to represent the lender’s
interests in the transaction. Use paragraph B for those referrals
to an attorney, credit reporting agency, or real estate appraiser
that a lender is requiring a borrower to use to represent the lender’s
interests in the transaction. When applicable, use both paragraphs.
Specific timing rules for delivery of the affiliated business disclosure
statement are set forth in 12 CFR 1024.15(b)(1) of Regulation X).
These INSTRUCTIONS TO PREPARER should not appear on the statement.]
