FORM DS-1 (DFI-Rev. 05/01/97) http://gitc.com/forms/
Compliments of Greater Illinois Title Company; for Internal and External Use.
Universal Doc Ref: G
P_IEF0017-20050804-R1-1
FORM DS-1 DISCLOSURE STATEMENT
(DFI-Rev.05/01/97) CONTROLLED BUSINESS ARRANGEMENT
(By a Producer of Title Insurance Business or Associate thereof)
This Disclosure is m
ade to: (Check one or both) ___________________Seller/Owner ___________________Buyer ____________________
Seller(s)/Owner(s) ________________________________________________________________________________________
[Print Name(s)] ______________________________
__________________________________________________________
Buyer(s) ______________________________
__________________________________________________________
[Print Name(s)] ________________________________________________________________________________________
Regar
ding the Property located at:
__________________________________________________________________________________________________________________
Stre
et City State Zip Code
For the T
itle Insurance Company, Title Insurance Agent, and/or Escrow Agent:
(Print Company Name)
GREATER ILLINOIS TITLE COMPANY
In connection with the property described above, the undersigned has recommended, or is about to recommend, the above named title insurance
company, t
itle agent, and/or escrow agent to the above named party(ies) to provide title insurance and/or escrow services.
The undersigned producer has a financial interest in the above names c
ompany/business, or is an associated of the party or entity which has said
financial int
erest and therefore, makes, or has made, the following estimate of the fees and charges that are known and which will be made in
connection with the recommended title a
nd/or escrow services.
Only those charges which may be paid by the party(ies) to whom t
his disclosure is made, are (were) disclosed herein. If there are additional parties
who c
hoose to utilize services from the above named company/business, there may be additional charges for those services.
* Owner’s Title Policy $ ______________________
* Mortgage Tile Policy: ______________________
Escrow or Closing Fee: ______________________
Other Fees: _______________ ______________________
Total Estimated Charges: $ _____________________
* These estimated figures include all charges/services such as title search, title examination, title insurance premiums, and final issuance of
Policy(ies). The
se estimates may be revised if any unusual circumstances occur, unusual risks are “insured over”, and/or lenders require special
endorsements which extends their coverage.
You are not required to use _______________________________________ (name of provider) as a condition for, settlement of your lo
an on, or
purchase, sale or refinance of the subject p
roperty. There are frequently other settlement service providers available with similar services. You are
free t
o shop around to determine that you are receiving the best services and the best rate for these services.
The u
ndersigned does hereby certify that the above disclosure was made to the above named party(ies) on _________________________________ .
Signature of Producer: _____________________________________________________
Date: ________________________________________
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ACKNOWLEDGEMENT
I/We have read this Disclosure form and understand that _____________________________________ (referring party) is referring me/
us to
purchase t
he above described settlement services from _____________________________________ (provider receiving referral) and may receive a
financial or other benefit as a res
ult of this referral.
Seller/Owner: _________________________________________________
Date: ___________________________________________
_________________________________________________
Date: ___________________________________________
Buyer: _________________________________________________
Date: ___________________________________________
_________________________________________________
Date: ___________________________________________
(NOTE: PURSUANT TO SECTION 18.(b) OF THE TITLE INSURANCE ACT, THE TITLE INSURANCE COMPANY, INDEPENDENT
ESCROWEE, OR TITLE INSURANCE AGENT SHALL MAINTAIN THIS DISCLOSURE FORM FOR A PERIOD OF 3 YEARS.)
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