STATE OF ARKANSAS SECURITIES DEPARTMENT HERITAGE WEST BUILDING, SUITE 300 201 EAST MARKHAM STREET LITTLE ROCK, AR 72201 TELEPHONE: 501.324.9260 FAX: 501.324.9268 Website: www.securities.arkansas.gov MORTGAGE BANKER/MORTGAGE BROKER/MORTGAGE SERVICER FMLA FORM 001 APPLICATION FOR LICENSE NOTE: PLEASE SUBMIT ORIGINAL FORMS ONLY; THE DEPARTMENT WILL NOT ACCEPT FAXED COPIES. PLEASE RETAIN A COPY FOR YOUR RECORDS. INCOMPLETE APPLICATIONS WILL BE RETURNED FOR COMPLETION. App Fee - See 2008 Fee Schedu Number of Branch Offices x $_______ = Total Fee (Non-refundable) 1. Name of Applicant: If business is operating in Arkansas under one or more assumed names (DBA), list name(s) below: (Attach a copy of the “Registered Fictitious Name” Certificate issued by the Arkansas Secretary of State’s Office for each assumed name listed.) 2. Principal Office Address: (Must be a physical address.) Address City State Zip Website Telephone Number Mailing address: (If different from above.) Fax Number Address City FMLA Form 001 State Zip Page 1 of 9 Effective Date: January 1, 2004 Amended: August 1, 2007 American LegalNet, Inc. www.FormsWorkflow.com 3. Applicant’s business activities. (Check all that apply.) Mortgage Broker Mortgage Banker Mortgage Servicer 4. Form of Organization (Sole Proprietorship, Partnership, Corporation, Limited Liability Company, etc.) (Attach a copy of the articles of incorporation, articles of organization, articles of partnership, or other such documents of organization filed with the appropriate regulatory authority in the State of organization, as well as copies of any documents issued by said regulatory authority granting approval of said filing. Additionally, attached are copies of any documents issued by the Arkansas Secretary of State granting approval to conduct business in Arkansas as a “foreign entity”, if applicable.) Federal Employer Identification Number: Date fiscal year ends: If publicly traded, give stock symbol: State of Incorporation/Organization: Date of Incorporation/Organization: 5. List the applicant’s affiliates. Complete FMLA Form 002 and attach. 6. List all persons having an interest in the business as principals, partners, officers, trustees, members, directors or managers. Complete FMLA Form 003 and attach. 7. Identify the Applicant’s Managing Principal. The Managing Principal must complete FMLA Form 014 and attach. Name Title Company Telephone Number Address Fax Number City FMLA Form 001 State Zip E-mail Address Page 2 of 9 Effective Date: January 1, 2004 Amended: August 1, 2007 American LegalNet, Inc. www.FormsWorkflow.com 8. List all states in which the Applicant is licensed to conduct business that includes the name, address, and telephone number of the regulatory authority for each state listed, as well as the license number for each state. Complete FMLA Form 005 and attach. 9. List all branch offices conducting business in the State of Arkansas. Complete FMLA Form 006 and attach. 10. List all loan officers conducting business in the State of Arkansas. Complete FMLA Form 007 and attach. 11. Attach the appropriate Arkansas corporate surety bond (FMLA Form 008) OR a deposit of cash and securities issued by the federal government, the State of Arkansas, or any political subdivision thereof, in the appropriate amount accompanied by an executed Arkansas “Assignment and Escrow Agreement” form (FMLA Form 009). The Applicant MUST use FMLA Form 008 or FMLA Form 009. No other forms 12. (A). Mortgage Banker and Mortgage Servicer 1. Attach audited financial statements that reflect a net worth of not less than $25,000.00 prepared by an independent certified public accountant and accompanied by an unqualified opinion. The audited financial statements must be as of a date not exceeding fifteen (15) months prior to the application date. (B). Mortgage Broker 1. Attach certified as true and correct by the president or chief financial officer of the mortgage broker financial statements reflecting that the applicant has a net worth of at least $25,000.00 prepared in accordance with generally accepted accounting principles as promulgated by the Financial Accounting Standards Board. The financial statements must be as of a date not exceeding eighteen (18) months prior to the application date. 2. Attach a “Certification of Unaudited Financial Statements for Mortgage Brokers Only,” signed and dated by either the President of the company or the Chief Financial Officer. 13. Attach an executed Arkansas “Consent to Service of Process” Form. Complete FMLA Form 010 and attach. 14 Location of records pertaining to mortgage loan transactions involving Arkansas consumers. _____________________________________________________________________________________ Address _____________________________________________________________________________________ State Zip Code City FMLA Form 001 Page 3 of 9 Effective Date: January 1, 2004 Amended: November 15, 2007 American LegalNet, Inc. www.FormsWorkflow.com 15. Applicant Contact Information Licensing Contact Name Title Company Telephone Number Address Fax Number City State Zip E-mail Address Regulatory/Compliance Contact Name Title Company Telephone Number Address Fax Number City State Zip E-mail Address Consumer Complaints Contact Name Title Company Telephone Number Address Fax Number City FMLA Form 001 State Zip E-mail Address Page 4 of 9 Effective Date: January 1, 2004 Amended: August 1, 2007 American LegalNet, Inc. www.FormsWorkflow.com 16. Please read the following questions carefully. Details to affirmative responses, other than subsection (s), must be reported on Page 8. Please list date(s), court name, case number, party(ies) and court ruling or judgment amount for each matter reported. (a) Have you ever been convicted of a crime punishable by one or more years imprisonment? Yes No (b) To the best of your knowledge, has the Applicant or any of its partners, directors, managers, executive officers, or controlling persons ever been convicted of a crime punishable by one or more years imprisonment? Yes No (c) To the best of your knowledge, have any loan officers or loan originators within the Applicant’s organization ever been convicted of a crime punishable by one or more years imprisonment? Yes No (d) To the best of your knowledge, are you a subject of any pending criminal investigation or proceeding? Yes No (e) To the best of your knowledge, are there any criminal investigations or proceedings pending against the Applicant or any of its partners, directors, managers, executive officers, or controlling persons? Yes No (f) To the best of your knowledge, are any loan officers or loan originators within the Applicant’s organization a subject(s) of any pending criminal investigation or proceeding? Yes No (g) Have you been a subject of any action, order or proceeding, pending or concluded, by any state or federal agency regulating the mortgage banking, mortgage brokering, or mortgage servicing industries during the past five (5) years? Yes No (h) Has the Applicant’s organization been a subject of any action, order or proceeding, pending or concluded, by any state or federal agency regulating the mortgage banking, mortgage brokering or mortgage servicing industries during the past five (5) years? Yes No (i) To the best of your knowledge, have any partners, directors, managers, executive officers, or controlling persons within the Applicant’s organization been a subject of any action, order or proceeding, pending or concluded, by any state or federal agency regulating the mortgage banking, mortgage brokering or mortgage servicing industries during the past five (5) years? Yes No FMLA Form 001 Page 5 of 9 Effective Date: January 1, 2004 Amended: August 1, 2007 American LegalNet, Inc. www.FormsWorkflow.com 16. (Continued) (j) To the best of your knowledge, have any loan officers or loan originators within the Applicant’s organization been a subject of any action, order or proceeding, pending or concluded, by any state or federal agency regulating the mortgage banking, mortgage brokering, or mortgage servicing industries during the past five (5) years? Yes No (k) Have you been a subject of any action, order, or proceeding by any state or federal agency regulating the banking industry, securities industry, insurance industry, or any other financial services industry during the past five (5) years? Yes No (l) To the best of your knowledge, has the Applicant or any partner, director, manager, executive officer or controlling person within the Applicant’s organization been a subject of any action, order, or proceeding by any state or federal agency regulating the banking industry, securities industry, insurance industry, or any other financial services industry within the past five (5) years? Yes No (m) To the best of your knowledge, has any loan officer or loan originator within the Applicant’s organization been a subject of any order, action, or proceeding by any state or federal agency regulating the banking industry, securities industry, insurance industry, or any other financial services industry within the past five (5) years? Yes No (n) Have there been any civil judgments entered against you arising from complaints alleging fraud, dishonesty, misrepresentation, theft, misappropriation, bad faith, deceptive trade practices, or predatory lending practices during the past five (5) years? Yes No (o) Have there been any civil judgments entered against the Applicant’s organization arising from complaints alleging fraud, dishonesty, misrepresentation, theft, misappropriation, bad faith, deceptive trade practices, or predatory lending practices during the past five (5) years? Yes No (p) Have you been named as a defendant in any pending civil court proceeding in which a complaint alleges fraud, dishonesty, misrepresentation, theft, misappropriation, bad faith, deceptive trade practices, or predatory lending practices? Yes No FMLA Form 001 Page 6 of 9 Effective Date: January 1, 2004 Amended: August 1, 2007 American LegalNet, Inc. www.FormsWorkflow.com 16. (Continued) (q) Has the Applicant been named as a defendant in any pending civil court proceeding in which a complaint alleges fraud, dishonesty, misrepresentation, theft, misappropriation, bad faith, deceptive trade practices, or predatory lending practices? Yes No (r) Has the Applicant ever filed for bankruptcy, or been ordered by a court of law to be placed into the hands of a receiver or conservator, or been subject of an assignment for the benefit of creditors, or been otherwise deemed insolvent? Yes No (s) Section twelve (12) of this application, located on page 3, requests that audited financial statements be submitted with this application. To the best of your knowledge, do the audited financial statements submitted herein accurately reflect the financial condition of the Applicant’s organization? Yes No FMLA Form 001 Page 7 of 9 Effective Date: January 1, 2004 Amended: August 1, 2007 American LegalNet, Inc. www.FormsWorkflow.com Instructions. This page should be used to report details of affirmative responses to questions on pages 5 through 7. Identify the question number for which additional information is being provided and insert the requested information. Copy this page as necessary and attach. Item No. FMLA Form 001 Answer Page 8 of 9 Effective Date: January 1, 2004 Amended: August 1, 2007 American LegalNet, Inc. www.FormsWorkflow.com STATE OF COUNTY OF ) ) ) The Applicant and its employees will comply with the provisions of Ark. Code Ann. § 23-39-501, et seq., (Fair Mortgage Lending Act). I understand that non-compliance may result in a suspension or revocation of the Applicant’s license. I further understand that any license issued is non-transferable and that, if the Licensee is sold or its organizational structure is changed, a new application must be filed. Pursuant to the Fair Mortgage Lending Act, the Applicant authorizes the Arkansas Securities Commissioner to conduct a financial and business responsibility background check as may be required to determine the general character and fitness of the Applicant, or any of its partners, directors, managers, executive officers, and/or controlling persons to engage in business as a mortgage banker, mortgage broker, or mortgage servicer. Further, the Applicant, its partners, directors, and executive officers or controlling persons hereby authorize the release of requested information necessary to facilitate the final determination of the Applicant by the Arkansas Securities Commissioner. I hereby swear or affirm that I am authorized to make this application and sign this statement on behalf of the Applicant, and that I have reviewed this application and the accompanying information submitted herein, including the audited financial statements, and that the information contained therein is true, accurate, correct, and complete to the best of my knowledge. I understand that the submission of false information to the Arkansas Securities Commissioner could result in the suspension or revocation of the Applicant’s license. I understand that it is unlawful pursuant to Section 23-39-516(a) of the Arkansas Fair Mortgage Lending Act for any person to make or cause to be made, in any document filed with the Arkansas Securities Commissioner, any statement that is, at the time and in light of the circumstances under which it is made, false or misleading in any material respect. Further, I understand that making or causing to be made a false or misleading statement as described above, if made willfully in a document filed with the Arkansas Securities Commissioner, is a Class B felony pursuant to Ark. Code Ann. Section 23-39-516(b), and carries a penalty of not less than five (5) years nor more than twenty (20) years imprisonment. (Signature) Date (Print Name) CEO/President/Managing Principal Subscribed and sworn to before me this ________ day of ________________, __________. NOTARY PUBLIC My Commission Expires: FMLA Form 001 Page 9 of 9 Effective Date: January 1, 2004 Amended: August 1, 2007 American LegalNet, Inc. www.FormsWorkflow.com