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Two blanks below are the brokerage’s to fill before this goes to a client: the ownership percentages, and FL Title’s fee ranges. Once they are in, print this, have the client sign, and file the signed copy against the deal.

AFFILIATED BUSINESS ARRANGEMENT DISCLOSURE STATEMENT

To:        ________________________________
Property:  ________________________________________
From:      Grand Miami Realty LLC
Date:      ________________

This is to give you notice that Grand Miami Realty LLC has a business relationship with FL Title & Escrow Co. Siarhei Zavadski owns 100% of Grand Miami Realty LLC and 100% of FL Title & Escrow Co. Because of this relationship, this referral may provide Grand Miami Realty LLC a financial or other benefit.

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 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.

    FL Title & Escrow Co
      Title insurance premium (promulgated by the
      Florida Department of Financial Services,
      varies with the purchase price)          Set by Florida rule — identical at any agency
      Settlement / closing fee                 $650 (standard)

    These are estimates only. Title insurance premiums in Florida are set by
    state rule and depend on the purchase price and loan amount; the actual
    figures for your transaction appear on your Closing Disclosure or
    settlement statement.

ACKNOWLEDGMENT

I/we have read this disclosure form, and understand that Grand Miami Realty LLC is referring me/us to purchase the above-described settlement service and may receive a financial or other benefit as the result of this referral.

Signature: ______________________________    Date: ______________

Signature: ______________________________    Date: ______________

Referring licensee: ________________________________
Grand Miami Realty LLC · Florida brokerage CQ1053747
1801 S Ocean Dr, Suite H, Hallandale Beach, FL 33009 · (800) 818-8571

Required by RESPA § 8 and Regulation X, 12 CFR § 1024.15. The wording follows the model format at Appendix D. This page is not indexed by search engines.