Prepared by, and after recording, return to: Name: Address: WARNING TO OWNER: The Florida Real Estate Sales Commission Lien Act (the "Act") provides that if you dispute the commission claimed in this commission notice, you must notify the closing agent of the dispute no later than 5 days after the closing. If you fail to notify the closing agent before that date that you dispute the claimed commission, you will be deemed to have confirmed the claimed commission and the Act will require the closing agent to pay the claimed commission to the broker from your net proceeds from the disposition of the commercial real estate. (Space reserved for Clerk of Court) BROKER'S COMMISSION NOTICE UNDER FLORIDA COMMERCIAL REAL ESTATE SALES COMMISSION LIEN ACT Notice is hereby given pursuant to the Florida Commercial Real Estate Sales Commission Lien Act, Part III of Chapter 475, Florida Statutes (the "Act"), that the undersigned real estate broker is entitled to receive a sales commission in the amount set forth below from the owner named below pursuant to the terms of a written brokerage commission agreement regarding the commercial real estate described below, and the undersigned broker claims a lien under the Act against the owner's net proceeds from the disposition of the commercial real estate. The Act and this commission notice do not create a lien against the commercial real estate itself, but only against the owner's net proceeds. This commission notice may be recorded in the public records of the county or counties where the commercial real estate is located. 1. 2. Name of the owner who is obligated to pay the commission: Legal description of the commercial real estate: . 3. Name, mailing address, telephone number, and Florida broker license number of the undersigned broker: Name: ___________________________________ Telephone number: ________________ License number: Mailing address: Effective date of the written brokerage commission agreement between the owner and the broker under which the commission is or will be payable: _______________, 20__. Amount of commission claimed by the undersigned broker: $______________, or ____________ percent of sales price, or [specify other formula for determination of commission amount]: . 4. 5. 6. The undersigned broker, under penalty of perjury, hereby swears or affirms that the undersigned broker has read this commission notice, knows its contents and believes the same to be true and correct, and that the undersigned broker is making this commission claim pursuant to the written brokerage commission agreement described in this commission notice. The undersigned broker confirms that this commission notice or a copy hereof has been delivered to the owner. Signed: Print Broker's name: (Broker) 7. State of _____________________ ) County of ___________________ ) Signed and sworn to or affirmed under penalty of perjury before me, a notary public, this _____ day of ____________, 20__, by ______________________________, who is personally known to me or produced ____________________ as identification. My commission expires: ____________________ [NOTARY SEAL] Form 475.705(1) - Sales Commission Notice.doc Signed: Notary Public, State of Print Notary's name: