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 OfficePick up your check in person at our office.

✉️

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

⚡

Electronic / Wire TransferReceive funds directly to your bank account.

5

Mailing Address

Where should we send your check?

📮

Street Address *

City *

State *

ZIP *

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

Type your full name to acknowledge and sign this authorization.

✍️

Agent Full Name (Digital Signature) * By typing your name you are digitally signing this document.

Date Auto-filled with today's date.