Payment Authorization Form Property Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Seller InformationSeller's Name* Listing Agent* Listing Brokerage* Buyer InformationBuyer's Name* Buyer's Agent* Buyer's Brokerage* Closing InformationTitle Company* Settlement Date* MM slash DD slash YYYY Sold Price*Commission InformationCommission % Earned*Commission Check Total*Calculate Your Commission CheckYour Name* Your Commission Split % (decimal amount)*Deduct marketing fee? (listings only)* Yes No Deduct office dues?* Yes No Amount to deduct for office dues*Total Commission $ to You*HiddenCommission $ to Flyer Homes*Referral FeesAre there any referral fees? (agent-to-agent, relocation, etc.)* Yes No Company receiving referral fee* Individual/Agent receiving referral fee* Referral fee amount*Name First Last
