<p> AFFIRMATION </p><p>Enter KW Agent’s Name, hereby affirms:</p><p>1. This affirmation is made in connection with the: (select one) ☐ Purchase/Sale; ☐ Leasing/Rental of the property know as:</p><p>Enter Property Address Apt# Enter Apt# City, State, Zip</p><p>2. I am the Agent for: Enter Consumer’s Name(s), the: (select one) ☐ Buyer; ☐ Seller; ☐ Landlord; ☐ Tenant;</p><p>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;</p><p>4. Such party has refused to sign the Agency Disclosure Form for the following reason(s);</p><p>Enter reason(s) for Refusing to sign the agency disclosure form______</p><p>5. I agree to maintain a copy of this Affirmation for no less than three (3) years from the date hereof.</p><p>______Date: ______Enter KW Agent’s Name Licensed Real Estate Select your Official DOS Title Keller Williams NYC</p><p>WITNESSED BY: </p><p>______Enter Witness Name</p><p>11 Page 1 of 1 AGENCY DISCLOSURE AFFIRMATION | VERSION DATE: 12/1/2012 </p>