BROKER NAME:__________________________________________

COMPANY NAME:_________________________________________

STREET ADDRESS:______________________________________________

CITY, STATE & ZIP:______________________________________________________

BROKER'S MASSACHUSETTS LICENSE #:__________________________

CLIENT'S NAME:____________________________________________________

IF CORPORATE, AUTHORIZED AGENT'S NAME:________________________________

CLIENT'S TELEPHONE #:______________________________

CLIENT'S SIGNATURE ACKNOWLEDGING YOUR REPRESENTATION:

X__________________________________________________________
_______________________

I, _____________________________, DO THIS THE ________ DAY OF _________________, HEREBY STATE THAT I AM ACTING IN MY CAPACITY AS A BROKER WITH THE ABOVE REFERENCED CLIENT, IN REGARD TO THEIR INTENDED PURCHASE OF THE REAL PROPERTY LOCATED AT 35 CLIFFWOOD STREET, LENOX, MASSACHUSETTS. I FURTHER STATE THAT I AM NOT A PRINCIPLE IN, NOR WILL I HAVE ANY FUTURE OWNERSHIP INTEREST IN THE PURCHASE OF 35 CLIFFWOOD STREET, LENOX, MASSACHUSETTS.

X________________________________________________