Enter KW Agent S Name, Hereby Affirms

AFFIRMATION

Enter KW Agent’s Name, hereby affirms:

1. This affirmation is made in connection with the: (select one) ☐ Purchase/Sale; ☐ Leasing/Rental of the property know as:

Enter Property Address Apt# Enter Apt# City, State, Zip

2. I am the Agent for: Enter Consumer’s Name(s), the: (select one) ☐ Buyer; ☐ Seller; ☐ Landlord; ☐ Tenant;

3. Pursuant to the New York State Real Property Law §443(2) I have attempted to first provide the Agency Disclosure Form to: Enter Name of party who Refused, the: (select one) ☐ Buyer; ☐ Seller; ☐ Landlord; ☐ Tenant on Enter Date of Refusal;

4. Such party has refused to sign the Agency Disclosure Form for the following reason(s);

Enter reason(s) for Refusing to sign the agency disclosure form______

5. I agree to maintain a copy of this Affirmation for no less than three (3) years from the date hereof.

______Date: ______Enter KW Agent’s Name Licensed Real Estate Select your Official DOS Title Keller Williams NYC

WITNESSED BY:

______Enter Witness Name

11 Page 1 of 1 AGENCY DISCLOSURE AFFIRMATION | VERSION DATE: 12/1/2012