DISCLOSURE OF DUAL AGENCY OR DUAL REPRESENTATION IN A RESIDENTIAL REAL ESTATE TRANSACTION
The undersigned do hereby acknowledge disclosure that:
The licensee ____________________ (name of broker or salesperson) associated with ____________________ (Brokerage Firm) represents more than one party in this residential real estate transaction as follows:
[ ] Seller(s) [ ] Buyer(s) [ ] Landlord(s) [ ] Tenant(s)
As a (select one):
[ ] standard agent [ ] limited service agent [ ] independent contractor
Brokerage Firm represents another party (select one):
[ ] Seller(s) [ ] Buyer(s) [ ] Landlord(s) [ ] Tenant(s)
As a (select one):
[ ] standard agent [ ] limited service agent [ ] independent contractor
[ ] Brokerage Firm represents two existing clients in the transaction and the undersigned acknowledge the following:
The undersigned understand that the foregoing dual agent or dual representative may not disclose to either client any information that has been given to the dual agent or representative by the other client within the confidence and trust of the brokerage relationship except for that information which is otherwise required or permitted by Article 3 (§ 54.1-2130 et seq.) of Chapter 21 of Title 54.1 of the Code of Virginia to be disclosed.
[ ] Brokerage Firm represents one existing client and one new client in the transaction and the undersigned acknowledge the following:
The undersigned understand:
The undersigned by signing this notice do hereby acknowledge their informed consent to the disclosed dual representation by the licensee.
____________________ | ________________________________________ |
Date | Name (One Party) |
____________________ | ________________________________________ |
Date | Name (One Party) |
____________________ | ________________________________________ |
Date | Name (Other Party) |
____________________ | ________________________________________ |
Date | Name (Other Party) |
Va. Code § 54.1-2139