Name: AMERISELLREALTY.COM, INC.

SSN or TIN: 11-3751311 Claimant #:

2010-A LOUISIANA REAL ESTATE LICENSEE EMERGENCY CLAIM FORM

The Gulf Co ast Clai ms Faci lity (GCCF) has set asid e an em ergency fund for elig ible real estate CLAIMANT NUMBER:
licensees, who suffered specified loss of income as a result of the Deepwater Horizon Spill. Th is is (Not to be filled in by Claimant)
not in tended as a fu ll rem edy and on ly certain clai ms are elig ible. This Clai m Fo rm is to b e
submitted by individuals or brokerage firms who wish to receive payment for loss of income suffered
as a resu lt of th e Deepwater Horizon Spill on April 20, 2010 and resulting oil discharges (“Spill”).
To learn more about filing a claim , go to www.larealtors.org/oilspill, call 1-800-266-8538 or visit a
listed Real Estate Professional Claims Facility Site Office (“Site Office”). NOTE: The funding for
this Emergency Claims Fund is to be provided by an independent third party, and is subject to
change at any time; no funds or payments from the Emergency Claim Fund are guaranteed,
and any Claim you file may or may not be paid. There is no guarantee of payment, as this fund
is voluntary on the part of the third parties who have offered to provide these funds, and
neither the Louisiana REALTORS® nor NCA make any promise or warranty that any funds
shall be available or claims paid. FUNDS HAVE BEEN ALLOCATED BY GCCF AND WILL
EXPIRE UPON USAGE OF FUNDS. FUND AVAILABILITY IS SUBJECT TO CHANGE
AT ANY TIME WITHOUT NOTICE.

I. INSTRUCTIONS
1. You m ay fi ll out a nd s ubmit a Cl aim Form and s upporting d ocuments to Nation al Catastrop he Adju ster (“NCA”) on line a t
http://www.larealtors.org/oilspill If yo u d o n ot sub mit yo ur claim o nline, fo llow In structions 2 -4 b elow and th e o ther in structions
contained in this Claim Form to submit your claim and sup porting documents by mail, email, overnight delivery, fax or i n person.
(See page 6 for contact information.)

2. Type your answers or print them in black ink, attaching additional information if n eeded. If yo u are an individual claimant, enter
your Social Se curity Number in the box at the top of eac h page. If y ou are a brokerage firm claimant, enter y our Tax Identification
Number.

3. NCA will assign you a Claimant Number. That Claimant Number will allow you to track the status of your claim online and will be
your claim identification number throughout the claims process. After submitting your application, you will get information on how
to monitor the status of your claim online or by phone. To contact NCA about the status of your claim, please dial 1-800-968-4456.

5. Claimants must have been actively-licensed in Louisiana at the time damages were incurred to be eligible under this fund. The only
claims allowed under this emergency fund are for tho se based on loss of income as a re sult of the Spill. Claims based on a loss of
commission for a specific transaction may only be filed by a broker or brokerage firm. C ommissions lost on both Residential &
Commercial sales are eligible. Both Brokers and sales associates may file individually for a loss of income. Claims that ARE NOT
ELIGIBLE for this fund include commercial real estate income, rental income, rental commissions and claims resulting from property
damage or ot her personal claims. These cl aims should be filed with the Gulf Coast Claims Facility directly. Lo ss of c ommissions
caused by the moratorium on drilling will not be considered. As this is an emergency fund, it is not designed to fully reimburse losses.
Initial claims are restricted to loss of income from April 20, 2010, through July 31, 2010. Subsequent claims may be filed for
loss of income from August 1, 2010, through October 31, 2010, and November 1, 2010, through January 31, 2011, depending
on fund availability. A separate claim will be required for each corresponding time period.

II. CLAIMANT INFORMATION

A. INDIVIDUAL CLAIMANT INFORMATION
All Individual Claimants must complete each question in this section. If you are applying as a brokerage firm and not as an individual,
please skip to section B below.

1. Last Name:

2. First Name:

3. Middle Name:

Street
4. Current Address:

Claim Form – Page 1

Name: AMERISELLREALTY.COM, INC. SSN or TIN: 11-3751311 Claimant #:

City State Zip

Parish Country

5. Home Phone
( | | ) | | | | - | | | | |
Number:
6. Cell Phone
( | | ) | | | | - | | | | |
Number:

7. Email Address:

8. Date of Birth: ___/___/____ (Month/Day/Year)

9. Social Security Number | | | | - | | | - | | | | |

or
Individual Taxpayer | | | | - | | | - | | | | |
Identification Number
(Check which is applicable.)

10. Are you a U.S. Citizen? Yes No

11. If Not, Proof of Legal Residency Attached: Yes No

12. Louisiana Real Estate License Number:

B. BROKERAGE FIRM CLAIMANT INFORMATION

This sectio n is to b e co mpleted ONLY if you a re applying as a brokera ge firm and n ot as an i ndividual cl aimant. All brokerage firm
Claimants must complete each question in this section.

B.1. Information about the Brokerage firm

13. Name of Brokerage AMERISELLREALTY.COM, INC. DBA SHARPMLS.COM

Firm & Trade
Name (if any):

Street
1022 SAINT PETER STREET #204
14. Brokerage firm City State Zip
Address: NEW ORLEANS LA 70116
Parish Countr y
ORLEANS USA
15. Phone Number: 888-657-5833
( | | ) | | /| 504-237-5833
| - | | | | |

16. Fax Number: ( | 866-466-8629

| ) | | | | - | | | | |

17. Website Address: HTTP://WWW.SHARPMLS.COM

Claim Form – Page 2

Name: AMERISELLREALTY.COM, INC. SSN or TIN: 11-3751311 Claimant #:

18. Employer Identification Number (EIN): | | 11-3751311

| - |
| | | | | | |

19. Registered Louisiana Real Estate License

Number for entity: BROK.0000009261.A-ACT
B.2. Information about the Brokerage firm Authorized Contact Person

20. Last Name: SMITH

21. First Name: JUDE
22. Middle Name: THOMAS
23. Title: BROKER/OWNER
24. Current Address Street

(if different from

1022 SAINT PETER STREET #204
Brokerage firm City State Zip Country
Address): NEW ORLEANS LA 70116 USA
25. Phone Number: ( | | ) | | | | - | |
888-657-5833 | | |

26. Cell Phone Number: ( | 504-237-5833

| ) | | | | - | | | | |

27. Fax Number: ( | 866-466-8629

| ) | | | | - | | | | |

28. Email Address: SHARPMLS@GMAIL.COM

III. CLAIM INFORMATION
CATEGORY OF LOSS OF INCOME CLAIM
Check applicable boxes for your claim. You may check more than one box. (By filling out this form for emergency funds you are not
relinquishing any legal rights in the future.) E nter t he am ount y ou are cl aiming n ow for eac h c laim ty pe. I f you have p reviously
received a payment, do not include that amount in the amount you are requesting. All Claimants must complete this section.

Claim Amount Claimed

1.________$ Total loss being claimed (Amount of total loss

should amounts in 2 and 3 immediately below.)
Cancellation of Sales Contract(s) (broker &
A. 2.________$ Total of loss Broker retains
brokerage firms only)
3.________$ Total of loss Broker to pay to sales associate

B. Lost Income due to Depressed Property Sales $ $75,000

Indicate any funds Claimant applied for from BP
C. $ $30,000-$50,000
previously 03458603
Indicate funds Claimant already received from BP.
D.
Funds paid under Claim #_____________________
$ 0.00
Indicate if you have previously filed a claim with
E $
NCA. Claim #______________________________

Claim Form – Page 3

Name: AMERISELLREALTY.COM, INC. SSN or TIN: 11-3751311 Claimant #:

For each claim type checked above, you must provide documentation or evidence of the damage or injury. Exhibit A to this Claim
Form lists the supporting documentation you must submit to support each claim type.

IV. LOST TRANSACTION CLAIMS (MAY ONLY BE FILED BY BROKER)

Complete this section if you are filing for a lo st transaction. You must provide documentation to support your claim, as directed on
Exhibit A.
1. Questions Claimants

Listing Broker Cooperating Broker (Circle)

29. Who is filing this claim?

a. Please provide: the date of cancellation, reason

for cancellation & the property address of the
failed transaction

b. Please provide the broker names and license

numbers of all brokers and sales associates who
were involved in the transaction (listing and
cooperating brokers).

c. Please provide the broker split between the

Claimant and Claimant’s sales associate. (Please
note the broker must file multiple claims for
multiple lost transactions.)

V. LOST INCOME CLAIMS

Complete this section if you seek lost earnings or profits due to the Explosion. You must provide documentation to support your claim,
as directed on Exhibit A.
1. Questions for All Claimants
All Claimants claiming lost earnings, cancellation of sales contracts, or profits must answer Questions 31-36
29. For any claim for a cancelled sales contract please provide
the property address and itemized commission lost for
each transaction. This section is only required for
transaction based losses. This information must include
all payments received from forfeited deposits or any other
payments received. If none then state.

30. Date you began losing income: For all claimants please
provide your market condition before your loss was
experienced.

Claim Form – Page 4

Name: AMERISELLREALTY.COM, INC. SSN or TIN: 11-3751311 Claimant #:

$ __________

31. Income in 2010 earned prior to April 20, 2010:

$ 3 5, 2 5 4. 2 2
32. Lost Income from April 20, 2010 – July 31, 2010
$ 2 2 , 5 00 . 00 $ __________

33. Lost income from August 1, 2010-October 31, 2010.

$15,500.00 $ __________

34. Lost income from November 1, 2010-January 31, 2011.

$ 1 8 , 5 0 0. 0 0
$ __________

35. What percentage of your income is derived from the sale

of real estate located in the listed parish for years 2007-
2010? $100%
__________%

36. Describe in detail how and why your market has been affected by the Spill. Please also provide a description of how your
market has been affected within the parishes described below. Attach additional pages if necessary:

SEE NEXT PAGE ATTACHED TO THIS DOCUMENT (PAGE 6)

VI. PAYMENT INFORMATION

A. CHECK INFORMATION
Provide the street address to which you would like the check(s) to be sent in the space below.
Street

37. Payment Address:

1022 SAINT PETER STREET #204
City State Zip Country
NEW ORLEANS LA 70116 USA

VII. SIGNATURE

Claim Form – Page 5

Name: AMERISELLREALTY.COM, INC. SSN or EIN: 11-3751311
113751311 Claimant #:

IV.C.2. Questions for Business Claimants Seeking Lost Earnings or Profits

(C.8) State the sources of income or types of customers for the business at the time of the Spill:
I AM A LICENSED REAL ESTATE BROKERAGE IN ARKANSAS, LOUISIANA, AND MISSISSIPPI, SPECIALIZING IN
THE GULF COAST REGION. I BELONG TO TEN MLS(S) MULTIPLE LISTING SERVICES, INCLUDING THE GULF
COAST REAL ESTATE INFORMATION NETWORK, GULF COAST AREA MLS, HATTIESBURG MLS, JACKSON MLS,
NORTHWEST MS MLS, BATON ROUGE AREA MLS, ALL HEAVILY AFFECTED BY THIS DISASTER. I REPRESENT
HOMESELLERS WITH AN AVERAGE HOMEVALUE OF $297,000.00.
(C.9) Describe the nature of business at the time of the Spill:
THE NATURE OF MY BUSINESS IS AS IT HAS ALWAYS BEEN SINCE INSUMPTION. I AM A LICENSED REAL ESTATE
BROKERAGE IN ARKANSAS, LOUISIANA, AND MISSISSIPPI, SPECIALIZING IN THE GULF COAST REGION. I BELONG TO
TEN MLS(S) MULTIPLE LISTING SERVICES, INCLUDING THE GULF COAST REAL ESTATE INFORMATION NETWORK, GULF
COAST AREA MLS, HATTIESBURG MLS, JACKSON MLS, NORTHWEST MS MLS, BATON ROUGE AREA MLS, ALL HEAVILY
AFFECTED BY THIS DISASTER. I REPRESENT HOMESELLERS WITH AN AVERAGE HOMEVALUE OF $297,000.00.

(C.10) Describe in detail any efforts you have made to increase revenues or reduce costs since the Spill:
I HAVE HAD TO INCREASE MY MARKETING BUDGET WITH REALTOR.COM FOR ADVANCED MARKETING RIGHT AROUND $1,000.00
MORE PER MONTH. IN ADDITION, I HAVE HAD TO SLASH MY FEES WEEKLY, BY AS MUCH AS 50% TO INTICE BUSINESS. I ALSO
DECREASED MY REFERRAL FEE SUBSTANTIALLY TO ATTRACT MORE PERSONAL REFERRALS FROM OTHER HOME MARKETING
FIRMS. I HAVE AND CONTINUE TO DEVOTE COUNTLESS HOURS IN THE FIELD PERSONALLY PROMOTING ME AND MY SERVICES. I
HAVE INVESTED THE REST OF MY SAVINGS AND ADDITIONAL TIME IN UPDATING MY BUSINESS PRACTICES ONLINE, IN HOPES OF
STAYING COMPETITIVE AND A LEADER IN THE INDUSTRY.

(C.11) State the total amount in operating costs you have saved (or were able to avoid) as a result $0.00
$_____________________
of reduced operations since the Spill:

(C.12) State the total loss in revenues the business has suffered as a result of the Spill to date and how you have calculated those
losses:
MY CLAIM IS FOR $56,500.00, WHICH IS ACTUAL LOSS FROM LOST REVENUE PLUS ADDITIONAL MEASURES
TAKEN TO INCREASE BUSINESS AND REDUCED FEES ACCEPTED TO INTICE CLIENTS. $75,000 IS MORE OF A
REASONABLE FIGURE, WHICH WOULD HAVE BEEN REALIZED HAD I NOT HAD TO UNDERGO THIS UNDUE
STRESS, WHICH HALTED MY PROGRESS, NOT TO MENTION THE TOLL THIS HAS TAKEN ON MY HEALTH, BOTH
PHYSICAL AND MENTAL, OF WHICH IS ONGOING AND TOO PRICELESS TO EVEN PUT A FIGURE ON.

(C.13) State the total loss in profits the business has suffered as a result of the Spill to date and how you have calculated those
losses:
$75,000 IS MORE OF A REASONABLE FIGURE, WHICH WOULD HAVE BEEN REALIZED HAD I NOT
HAD TO UNDERGO THIS UNDUE STRESS, WHICH HALTED MY PROGRESS, NOT TO MENTION THE
TOLL THIS HAS TAKEN ON MY HEALTH, BOTH PHYSICAL AND MENTAL, OF WHICH IS ONGOING
AND TOO PRICELESS TO EVEN PUT A FIGURE ON.

(C.14) Provide a description of the loss the business sustained as a result of the Spill and how the loss occurred:
I BELIEVE THAT QUESTION TO BE INSULTING AND INSENSITIVE, NO MATTER WHO YOU ASK OR WHAT PROFESSION THEY ARE IN.
FROM DAY ONE, THE DOOM AND GLOOM AND UNCERTAINTY OF WAY OF LIFE, OUR FAMILIES, OUR HOMES, OUR LIVELIHOOD,
HAVE ALL SHATTERED THE VERY LIFE OUT OF US. EVERTHING I HAVE PUT INTO THE GULFSOUTH REGION IN HOPES OF A
BRIGHTER AND BETTER FUTURE ARE UP IN SMOKE. PEOPLE DO NOT WANT TO MOVE HERE. THOSE WHO DO LIVE HERE, ARE
UNABLE TO MOVE AND SELL THEIR HOMES. THAT IS THE RESULT OF WHAT IS GOING ON HERE WITH GLIM FORCAST OF YET TO
COME.

(C.15) Provide the business address where the loss occurred:

I BELONG TO TEN MLS(S) MULTIPLE LISTING SERVICES, INCLUDING THE GULF COAST REAL ESTATE
Street
INFORMATION NETWORK OF METRO NEW ORLEANS, GULF COAST AREA MLS, HATTIESBURG MLS,
JACKSON MLS, NORTHWEST MS MLS, BATON ROUGE AREA MLS, ALL HEAVILY AFFECTED BY THIS
City
DISASTER. I AM IN THE BUSINESS OF SELLING HOMES. State Zip Code
EVERY ADDRESS WHERE A LOSS OCCURRED
IS THE BUSINESS ADDRESS WHERE MY LOSS OCCURRED AND CONTINUES TO OCCUR.
Parish/County

Interim Payment Claim Form – Page 8

Name: AMERISELLREALTY.COM, INC. SSN or TIN: 11-3751311 Claimant #:

I certify that the inform ation prov ided in this Clai m Form is true and accurate to the be st of m y knowledge, a nd I understa nd t hat false
statements or claims made in connection with this Claim Form may result in fines, imprisonment, and/or any other remedy available by law
to the Federal Government, and that suspicious claims will b e forwarded to federal, state, and local law enfo rcement agencies for possible
investigation and prosecution.

By submitting this Claim Form, I conse nt to the use an d disclosure by NCA and those assisting NCA of a ny information about me that it
believes necessary and/or helpful to process my clai m for compensation and any a ward resulting from that clai m, including a ny appeal of
that award, and/or as otherwise required by law, regulation or judicial process.

By signing below, claimant shall and does hereby agree to hold Louisiana Realtors and NCA and their respective officers, employees,
agents, or other representatives wholly harmless for any and all causes of action, claims, damage, loss, costs and expenses whatsoever
(including attorneys' fees) arising out of this claim and from any cause or causes. Such causes include, but are not limited to, Louisiana
Realtors or NCA's negligence, errors, omissions, strict liability, breach of contract, or breach of warranty. Neither Louisiana Realtors nor
NCA assume any liability for damages to others which may arise on account of this claims process.

12 ___/___/____
29 2010
Signature: Jude Thomas Smith
Jude Thomas Smith (Dec 29, 2010)
Dec 29, 2010
Date: (Month/Day/Year)

First Middle Last

Printed Name:
JUDE THOMAS SMITH
Title, if a
Brokerage firm: BROKER/OWNER
Has anyone assisted you in the preparation of this Claim Form? No

Name of individual and company, if applicable:

Claim Form – Page 6

Name: AMERISELLREALTY.COM, INC. SSN or TIN: 11-3751311 Claimant #:

HOW TO SUBMIT THIS CLAIM FORM

Submit this Claim Form and the supporting documents required in Exhibit A to NCA by one of the following methods:

Regular Mail: Overnight, Certified or Registered Mail: Fax:

NCA Group NCA Group (317) 915-8895
Realtors Administrator Realtors Administrator
9725 Windermere Blvd. 9725 Windermere Blvd. Online:
Fishers, IN 46037 Fishers, IN 46037 http://www.larealtors.org/oilspill

When at taching y our su pporting d ocuments, be su re t o p rovide t he appropriate identifi cation num ber (your Social Security Number , or
other Tax Identification Number). On Exhibit A to this Claim Form, check off each type of document you are submitting in support of your
claim. Attach all supporting documents to the Claim Form and submit your Claim to NCA Group.

Description of Eligible Parishes for Emergency Payment

All emergency claims will be considered not just based on damages but also location of Claimant’s business practice. Each claimant is
required to stipulate and provide supporting documentation for their area of real estate brokerage practice. The following parishes are
identified as falling within the emergency areas affected by the Spill:

Assumption, Calcasieu, Cameron, Iberia, Jefferson, Lafayette, Lafourche, Orleans, Plaquemines, St. Bernard, St. Landry, St. Martin, St.
Mary, St. Tammany, Terrebonne and Vermillion.

Claim Form – Page 7

Name: AMERISELLREALTY.COM, INC. SSN or TIN: 11-3751311 Claimant #:

2010-B SUPPORTING DOCUMENTATION FOR INDIVIDUAL AND BROKERAGE FIRM CLAIMS

EXHIBIT A

You must provide documentation for each claim. If you do not have each of the documents required for payment but have another type of
proof that you b elieve supp orts you r clai m, ch eck the last ite m o n the list, “O ther pr oof, if applicable,” and pr ovide th at documentation.
Provide as many types of such documentation as yo u have available. NCA Grou p will ev aluate your claim based on th e information and
documentation you submit and will contact you if additional documentation is necessary.

Use the check boxes beside each type of documentation to indicate whether providing that document. Pe r LA R.S. 37:1446, only a broker
of record may receive compensation that is related to a real estate transaction.

2010-B I. SUPPORTING DOCUMENTATION FOR INDIVIDUAL CLAIMS

EXHIBIT A

This section of Exhibit A applies to Individual Claimants only. Brokerage firm Claimants should proceed to the next section of
Exhibit A. You m ust provide documentation for each cl aim. If you do not ha ve each of the doc uments required for paym ent but ha ve
another type of proof that you believe supports your claim, check the last item on the list, “Oth er proof, if ap plicable,” and provide that
documentation. Prov ide as many types of such documentation as you have available. NCA Group will evaluate your claim based on the
information and documentation you submit and will contact you if additional documentation is necessary.

Use the check boxes beside each type of documentation to indicate whether you are providing that document.

LOSS OF INCOME CLAIMS – INDIVIDUALS

Documents for Claimants Seeking Emergency
Document
Advance Payments
Self-prepared documents itemizing sale transactions from 2007-2010
1. describing market location and activity as a licensed real estate licensee
(number of sales, closing dates, price ranges, addresses).
Description of parishes in which claimant primarily conducts real estate
2. brokerage activities, and explanation providing details on efforts to
mitigate losses or why no efforts were taken.
Copies of cancelled contracts for sale or evidence of cancelled contracts
3.
for listing for sale.
Signed copies of income tax returns and schedules for 2007-2009.
4. Monthly income reports for January 2010 through April 2010. (Individual
claimants are only required to submit tax returns.)
Documentation of unemployment compensation or other government
5.
benefits received.

6. Doc umentation of payments received from private insurance.

Provide a detailed explanation of your economic need for this emergency

7.
payment.

8. Other proof, if applicable.

Exhibit A: Supporting Documentation – Page 1

Name: AMERISELLREALTY.COM, INC. SSN or TIN: 11-3751311 Claimant #:

2010-B II. SUPPORTING DOCUMENTATION FOR BROKERAGE FIRM CLAIMS

EXHIBIT A

This section of Exhibit A applies to Brokerage firm Claimants only. The Brokerage firm Claimant must provide documentation for
each type of i njury or dam age claim ed in Section IV.C of t he Claim Form. If t he Brokerage firm Claimant does not have e ach of the
documents required for a payment but has another type of proof that the Brokerage firm Claimant believes supports its claim, check the last
item o n th e li st, “Oth er proo f, if ap plicable,” and p rovide t hat doc umentation. Pr ovide as m any types of suc h doc umentation as th e
Brokerage firm Cla imant has available. NCA Grou p will evaluate the claim based on the information and documentation submitted and
will contact the Authorized Brokerage firm Representative if additional documentation is necessary.

Use the check boxes beside each type of documentation to indicate whether the Brokerage firm is providing that document.

LOSS OF INCOME CLAIMS - BROKERAGE FIRMS

Documents for Brokerage firm Claimants
Document
Seeking Emergency Advance Payments

1. Documents providing description of Brokerage losses due to the Spill.

Documents itemizing sale transactions from 2007-2010 describing market

2.
location and activity as a licensed real estate professional.
Copies of monthly financial statements for 2007-2010. (If new or start-up
3. Brokerage firm, provide all available financial statements and a Brokerage
firm plan.)
Copies of letters to Brokerage firm detailing cancellations caused by the
4.
Spill. (Cancelled listing agreements, etc.)
5. Signed copies of income tax returns and schedules for 2007-2009.
Documents providing details on efforts to mitigate losses or why no efforts
6.
were taken.

7. Documentation of payments received from private insurance.

8. Documentation demonstrating canceled contracts.

9. Record of monthly sales for January 2007 – December 2009

10. Monthly sales records from January 2010 through July 2010

Provide a detailed explanation of your economic need for this emergency

11.
payment.

12. Other proof, if applicable.

Exhibit A: Supporting Documentation – Page 2

Name: AMERISELLREALTY.COM, INC. SSN or TIN: 11-3751311 Claimant #:

2010-B III. SUPPORTING DOCUMENTATION FOR LOSS OF TRANSACTIONS CLAIMS

EXHIBIT A

This section of Exhibit A applies to loss of transactions only and may only be filed by a broker/brokerage firm. The Claimant must
provide documentation for each type of i njury or damage claimed in Section IV of the Claim Form. I f the Brokerage firm Claimant does
not have each of the documents required for a payment but has another type of proof that the Brokerage firm Claimant believes supports its
claim, check t he last item on the list, “Ot her p roof, i f a pplicable,” a nd provide t hat d ocumentation. Pr ovide as m any t ypes o f su ch
documentation as the Brokerage fi rm Claimant has a vailable. NCA will evaluate the claim based o n the information and documentation
submitted and will contact the Authorized Brokerage firm Representative if additional documentation is necessary.

Use the check boxes beside each type of documentation to indicate whether the Brokerage firm is providing that document.

LOSS OF TRANSACTION CLAIMS

Document

1. Li sting Agreement

MLS information reflecting offer of compensation or any other commission

2.
agreements or other commission communications.
Independent Contractor Agreement or other documentation reflecting split
3.
between broker and sales associate.
Cancellation information, letters, and all relevant communication regarding
4.
lost transaction due to oil spill as cause of collapse of transaction.
Documents providing details on efforts to mitigate losses or why no efforts
6.
were taken.

7. Documentation of payments received from private insurance.

8. A detailed explanation of your economic need for this emergency payment.

9. Other proof, if applicable.

Exhibit A: Supporting Documentation – Page 3

 LOUISIANA REAL ESTATE
LICENSEE EMERGENCY
CLAIM FORM_Louisiana_2010-
A_Jude Thomas Smith
EchoSign Document History December 29, 2010

Created: December 29, 2010

By: Jude Thomas Smith (sharpmls@gmail.com)

Status: SIGNED

Transaction ID: XMXZCA2N335G2C

“LOUISIANA REAL ESTATE LICENSEE EMERGENCY CLAIM

FORM_Louisiana_2010-A_Jude Thomas Smith” History
Document created by Jude Thomas Smith (sharpmls@gmail.com)
December 29, 2010 - 3:25 PM CST - 184.38.17.107

Document esigned by Jude Thomas Smith (sharpmls@gmail.com)

December 29, 2010 - 3:27 PM CST - 184.38.17.107

Signed document emailed to Jude Thomas Smith (sharpmls@yahoo.com) and Jude Thomas Smith
(sharpmls@gmail.com)
December 29, 2010 - 3:27 PM CST