Affiliated Business Disclosure Statement



This is to give you notice that [referring party] has a business relationship with [settlement service provider] [Describe the nature of the relationship between the referring party and the provider, including percentage of ownership, if applicable.] Because of this relationship, this referral may provide [referring party] a financial or other benefit.

Set forth below is the estimated charge or range of charges by [provider] 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 or 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 Services                                    Estimated Charge or Range of Charges

________________________________        $ ___________________________

________________________________        $ ___________________________

________________________________        $____________________________


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] ___________________________[signature]


Specific timing rules for delivery of the affiliated business disclose statement are set forth in 24 CFR 3500.15(b)(1) of Regulation X.


No guidelines are available for this form at this time.