8/18/2019 Brokerage Relationship - Unrepresented Party

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DISCLOSURE OF BROKERAGE RELATIONSHIPFOR UNREPRESENTED PARTY(IES)

Property Address/_______________________________________________________________________________

The undersigned unrepresented party (ies) do hereby acknowledge disclosure that the licensee _________________________________________________________ (Broker or Salesperson) associated with _________________________________________________________ (Brokerage Firm) represents only thefollowing party in a real estate transaction:

Seller(s) OR   Landlord(s)

Buyer(s) OR  Tenant(s)

SIGNATURE OF UNREPRESENTED PARTY

Print Name

 /Date Signature

SIGNATURE OF UNREPRESENTED PARTY

Print Name

 /Date Signature

Disclosure Unrepresented

CVR 400 Rev 11/12

This form was produced by Barbara Chambers. CVR MLS forms may be used only by members in good standing ofthe Central Virginia Regional MLS.