COMMISSION INVOICE

INVOICE FROM

Name / Entity: _____________________________________________

Address: _____________________________________________

Address (cont.): _____________________________________________

Country: _____________________________________________

Tax / VAT No.: _____________________________________________

Bank Name: _____________________________________________

Account Name: _____________________________________________

Account Number: _____________________________________________

Sort Code / SWIFT: _____________________________________________

IBAN: _____________________________________________

INVOICE TO

Name / Entity: _____________________________________________

Address: _____________________________________________

Address (cont.): _____________________________________________

Country: _____________________________________________

Tax / VAT No.: _____________________________________________

Invoice Number: _____________________________________________

Invoice Date: _____________________________________________

Payment Due: _____________________________________________ (30 days from invoice date)

Mandate Ref.: _____________________________________________

Agreement Ref.: _____________________________________________ (Commission Agency Agreement dated _____________)

Currency: _____________________________________________

Commission Summary

Note on Base Value:

The base value for commission calculation is the _______ value of the transaction as specified in the Commission Agency Agreement dated _____________, and does not include any taxes, freight, insurance, or other charges unless expressly agreed.

Tax / VAT Position

Service Provider Tax Jurisdiction: _____________________________________________

VAT / GST Registration Number: _____________________________________________

VAT / Tax Rate Applied: _____% Amount: _____________

Total Amount Including Tax: _____________________________________________

Payment Instructions

Please remit the full amount due to the bank account stated above. Payment shall be made by bank transfer only. Cheques and cash are not accepted.

Payment Reference to Use: _____________________________________________

Expected Value Date: _____________________________________________

If payment is not received within thirty (30) days of the invoice date, interest shall accrue on the outstanding amount at the rate specified in the Commission Agency Agreement.

Declaration

I / We confirm that the commission set out in this invoice has been earned in accordance with the Commission Agency Agreement referenced above, that the Commission Event has occurred as defined therein, and that this invoice is a true and accurate record of the commission due.

Signed on behalf of the Invoicing Party:

Authorised Signatory: _____________________________________________

Full Name: _____________________________________________

Title: _____________________________________________

Date: _____________________________________________

ACKNOWLEDGEMENT OF RECEIPT (to be signed by the paying party and returned)

We acknowledge receipt of this Commission Invoice and confirm that payment will be made by the due date stated above.

Signed: _______________________________ Date: _______________ Name: _________________________

Doc 05 — Commission Invoice Template — Neutral Template