Filing Date? *

Has the bankruptcy been discharged? *

Type of bankruptcy? *

About the Property

Agent hereby offers to sell to Commission Funding Solutions (“CFS”), the “Commission” described below. Contract Information: (The “Contract”)

Property Address *

Buyer(s) Name(s) *

Seller(s) Name(s) *

Escrow/Title Co. *

Escrow/Title Phone Number *

Escrow/Title Co. Officer Name *

Escrow/Title Company Address *

Escrow/Title Co. Officer Email *

Property Sale Type *

Earnest Deposit *

$

Down Payment *

$

Final Contract Price *

$

Settlement Date *

Escrow Reference # *

Commission Information: (The "Commission")

Receivable (Agent’s share of Commission after ALL expenses and deductions): $ *

$

How much of your Commission would you like to receive in your bank account ? $ *

$

Transaction Representation: *

Listing Agent

Selling Agent

Both

Do you currently have any open advances with other commission advance companies? *

Which commission advance company? *

Are you a first time client? *

Additional Information (Optional)

How did you hear about us? *

Declaration:

I declare under penalty of perjury that each of the representations and acknowledgements contained in this Application were and remain true and correct to the best of my information and belief. Furthermore, I acknowledge that any intentional or negligent misrepresentation of the information contained in this Application may result in civil liability and/or criminal penalties and liability for monetary damages to Commission Funding Solutions, its agents, successors and assigns, insurers and any other person who may suffer any loss due to reliance upon any misrepresentation which I have made on this Application. Should Commission Funding Solutions choose to do so, I authorize Commission Funding Solutions to review my credit history and any other information in order to approve or decline my business application, service my account, and manage its relationship with me. I also agree and consent to the exclusive jurisdiction of the courts of the State of California for all purposes regarding this Contract and further agree and consent that venue of any action brought hereunder shall be exclusively in North County, San Diego.

I acknowledge the above declaration *

Yes

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