Broker Commission Disbursement Authorization

1

Transaction Information

Basic details about the real estate transaction.

🏠

File Number *

Closing Date *

Property Address *

Seller Name *

Buyer Name *

2

Agent Information

Details about the listing agent and brokerage.

👤

Broker / Company Name *

Agent Full Name *

Phone Number *

Agent Email Address *

3

Commission Information

Enter the commission amounts for this transaction.

💰

Commission Amount to Agent *

$

Broker Fee

$

Total Commission AUTO

$

Commission + Broker Fee

4

Delivery Preference

Select how you would like to receive your commission.

📬

🏢

Check Pickup at Title Office Pick up your check in person at our office.

✉️

Check Mailed via Postal Service We will mail the check to the address you provide.

⚡

Electronic / Wire Transfer Receive funds directly to your bank account.

5

Mailing Address

Where should we send your check?

📮

Street Address *

City *

State *

ZIP Code *

5

Wire Transfer Details

Provide your banking information for the wire transfer.

🏦

⚠️

A $20.00 wire fee will be deducted from the commission proceeds. Please verify all banking details carefully — wire transfers cannot be reversed.

Financial Institution Name *

Account Holder Name *

Routing Number *

Account Number *

Additional Reference / Notes

6

Authorization & Confirmation

Review and confirm the accuracy of this submission.

✅

I confirm that the broker authorizes this commission disbursement and that all information provided is accurate and complete. I understand that this submission constitutes a formal disbursement instruction to C to C Title Solutions Corp, and that the broker will provide the appropriate tax reporting to the agent for this transaction.

7

Digital Signature

Draw your signature to authorize this submission. Your signature metadata will be captured and embedded in the document.

✍️

Draw Your Signature *

Sign here using your mouse, stylus, or finger

Printed Name * Your printed name as it will appear in the signature certificate.

Date Auto-filled with today's date.

By drawing your signature and clicking Submit Authorization, you agree that your electronic signature is legally equivalent to your handwritten signature. Your IP address, signing timestamp, and signature image will be recorded in the document.