T-00 TX Verification of Services Rendered

VERIFICATION OF SERVICES RENDERED – Form T-00
INSTRUCTIONS 

1. The Agent/Entity desiring to be paid shall complete Section 1, sign, date and deliver the form, together with a written itemized statement or invoice, when the work is performed or delivered.
2. The Agent/Underwriter issuing the policy shall complete Section 2.
3. The Agent/Underwriter paying for the work shall complete Section 3, sign, date and deliver a copy of the form to both the Agent/Entity being paid and the Agent/Underwriter issuing the policy.
4. All parties shall retain in their records a fully signed copy of this Form T-00 and a copy of the written itemized statement or invoice. 

SECTION 1 – INFORMATION FROM AGENT/ENTITY REQUESTING PAYMENT
1. Service for which payment is requested:  
o         Furnishing Title Evidence
o         Title Examination
o         Closing the Transaction

Address of location where work was done for selected service(s): ________________________________________________________________ 
Order/File/GF# assigned to this order by Agent/Entity doing the work: ________________________________________________________________ 

2. AGREEMENT REGARDING PAYMENT FOR SERVICE:
Percentage or amount of premium (remaining after remittance to Underwriter) agreed to be paid to the Agent/Entity doing the work:
____________________%            or        $_________________________ 

3. INFORMATION ABOUT AGENT/ENTITY DOING THE WORK:
Type of entity:
o Texas Underwriter           
o Texas Title Agent   
o Texas Attorney at Law or Texas PC organized to provide legal services
Name: _______________________________________________
Address: _______________________________________________
City, State/ZIP_______________________________________________
Firm ID Number or Texas State Bar #:  _____________ 

Undersigned certifies that the service for which payment is requested was actually performed.
__________________________________                    Date: _____________
Signature of Authorized Representative
for Agent/Entity Doing the Work 

SECTION 2 – INFORMATION FROM AGENT/UNDERWRITER ISSUING THE POLICY
4. Date of Policy (ies): ________________ County Code(s): __________________            Order/File/GF# assigned to this Policy (ies) by Issuing Agent/Underwriter:      ___________________ 
5. Issue Type:    
o   Out-of-County (2) – Title Evidence from Texas Agent
o     Multi-County (1) – Title Evidence from Texas Agent
o   Best Evidence (0) – No title evidence from Texas Agent  

6.Liability and Premium Amount(s):
Owner Title Policy (ies) Liability: $_____________ Premium: _________________
Mortgagee Policy (ies) Liability: $______________Premium: $ ________________
Endorsement(s)                                                                                $______________
Other                                                                                                 $______________

                                                                      TOTAL                         $______________ 

Final amount remaining after remittance to the Underwriter:       $_____________
Final amount paid to the Agent/Entity doing the work:                  $_____________ 

7.  INFORMATION ABOUT AGENT/UNDERWRITER ISSUING POLICY:

Name: ________________________________________________
Address: ________________________________________________
City, State/ZIP  ________________________________________________
Firm ID Number: _______________________________  

SECTION 3 – INFORMATION FROM AGENT/UNDERWRITER PAYING FOR THE WORK
8.  INFORMATION ABOUT AGENT/UNDERWRITER PAYING FOR THE WORK:
Name:  ________________________________________________
Address:  ________________________________________________
City, State/ZIP  ________________________________________________
Firm ID Number: _______________________________     

       
Order/File/GF# assigned to this order by Agent/Underwriter paying for the work:             __________________

Undersigned certifies that the above description of work performed is accurate and the final amount shown paid is correct.

 ________________________________                                    Date: ________________
Signature of Authorized Representative
for Agent/Underwriter Paying for the Work