• 
  

• Realtor Disclosure Form

• 
  
• Realtor Name*
• Agency Name*
• Agency Address*

  Street Address 1

  Street Address 2

  City

  State/Province/Region

  Postal/Zip Code

  Country
• Phone*

  --
• 
  
• Client Name*
• Client Name*
• Client Address*

  Street Address 1

  Street Address 2

  City

  State/Province/Region

  Postal/Zip Code

  Country
• Phone*

  --
• 
  

• Disclosure Information

• 
  
• Agency Relationship* Select Buyer's Agent: Represents the buyer, with fiduciary duties Seller's Agent: Represents the seller, with fiduciary duties Dual Agent: Represents buyer and seller, with permission from both
• I/We have been informed of the 2024 changes to the real estate commission structure.*

  Yes No
• Commission Structure* Select Commission to be paid by the buyer Commission to be paid by the seller's agent *Other (explain below)
• *Explain the commission structure to be used*
• 
  
• Potential Conflicts of Interest*

  No conflict of interest I may represent clients with shared interest in a property I may have personal interest in a property transaction I may have financial interest in a property I may be related to the buyer/seller
• 
  
• Buyer/Seller Signature*
• Date*
• 
  
• Realtor/Broker Signature*
• Date*
•