Paycheck Request Form

Name of Agent:
Address of Subject Property:
Was Property Listed on FMLS:	Yes No
FMLS# of Subject Property:
Sales Price of House:
Agent Commission Percentage:
Amount of Check Collected at Closing:
Amount of Earnest Money Still being Held by Homewise:
Total Amount of Commission associated with closing:
Total of A times your Commission Rate:
Amount of E & O Insurance (Deducation):
Gratuity you are offering Jame for a Job Well Done (Deduction):
Sales Price times FMLS fee of .0012 (Deduction):
Any other Deductions from Check (Deduction):
Total Deductions:
Net Commission Check: