STATE OF CALIFORNIA - DEPARTMENT OF BUSINESS OVERSIGHT STATEMENT OF IDENTITY AND QUESTIONNAIRE DBO-512 SIQ (Rev. 5-17) File Number, if any Licensee (Company Name) Insert Department of Business Oversight file number, if any, and the name of the licensee (company) to which this Statement of Identity and Questionnaire relates. Legal Full Name First Name Middle Name Last Name (Do not use initials or nicknames) Position to be filled in connection with the preparation of this questionnaire (e.g., Officer, Director, Manager, etc.). Sex Hair Eyes Height Weight Birthdate Birthplace Social Security Number California Driver's License Number -G regarding (if none, so state) whether furnishing the social security number is mandatory or voluntary and for a description of the use made of that information. Residence Phone Number Business Phone Number Email Hours of Employment Address (e.g., 8:00 a.m. to 5:00 p.m.) 1.Residence addresses for the last 10 years: From To Street City State Zip Code Present Attach separate schedule if space is not adequate. American LegalNet, Inc. www.FormsWorkFlow.com Insert Full Name Insert Licensee of Individual: (Company Name): 2 2.Employment for the last 10 years: From To Employer Name and Address Occupation and Duties Present Attach separate schedule if space is not adequate. 3.a. Have you ever been named in any order, judgment or decree of any court or anygovernmental agency or administrator, temporarily or permanently restraining or enjoining youfrom engaging in or continuing any conduct, practice or employment? Yes No If the answer is "Yes", give details: Attach a copy of any order, judgment or decree. b.Are you currently, or have you been within the last ten years, under federal, state or localinvestigation for possible violation of any law, ordinance, or licensing or regulatory scheme? Yes No If the answer is "Yes", give details: 4.a. Are you currently licensed to engage in financial business in this state or any other state?Yes NoFinancial business means securities broker-dealer or agent, investment adviser or investmentadviser representative, financial planner, insurance agent, escrow agent, finance lender orbroker, mortgage lender or servicer, real estate broker, payday lender, financial institution, billpayer or prorater, commodity sales person, certified public accountant, or any other businessinvolving investment or financial transactions.If the answer is "Yes", describe in the chart on the next page the following for each license: American LegalNet, Inc. www.FormsWorkFlow.com Insert Full Name Insert Licensee of Individual: (Company Name): 3 License Period From: To: License Number Type of License/Business Name and Address of Licensing Entity Attach separate schedule if space is not adequate. b.Have you ever been refused a license to engage in any business in this state or any otherstate, or has any such license ever been suspended, revoked, or surrendered subject to asettlement, or any other similar action? Yes No If the answer is "Yes", give details: Attach a copy of any settlement. 5.Have you ever been convicted of or pleaded nolo contendere to a misdemeanor or felony otherthan minor traffic citations that do not constitute a misdemeanor or felony offense?"Convicted" includes a verdict of guilty by judge or jury, a plea of guilty or of nolo contendere or a forfeiture of bail. All convictions must be disclosed even if the plea or verdict was thereafter set aside and the charges against you dismissed or expunged or if you have been pardoned. Convictions occurring while you were a minor must be disclosed unless the record of conviction has been sealed under Section 1203.45 of the California Penal Code or Section 781 of the California Welfare and Institution Code. Yes No If the answer is "Yes", give details: Attach a copy of any order, judgment or decree. If a conviction was entered under Section 23152(a) of the Vehicle Code, attach a written declaration stating whether drugs were involved. 6.Have you ever been a defendant in a civil court action other than divorce, condemnation orpersonal injury? Yes No If the answer is "Yes", please complete the following: Date of suit Location of court Nature of suit Attach a copy of any order, judgment or decree. American LegalNet, Inc. www.FormsWorkFlow.com Insert Full Name Insert Licensee of Individual: (Company Name): 4 7.Have you ever been a subject of a bankruptcy or a petition in bankruptcy? Yes No If the answer is "Yes", give date, title of case, location of bankruptcy filing: 8.Have you ever been refused a bond, or have you ever had a bond revoked or canceled? Yes No If the answer is "Yes", give details: 9.Have you any name other than that herein listed? Yes No If so, explain. Change in name through marriage or court order and exact date of each name change must be listed. Prior Name Date of Name Change 10.Have you ever done business under a fictitious firm name either as an individual or in any formof business, e.g. partnership, limited liability company, corporation or other? Yes No If the answer is "Yes", give details: The following questions must be answered by all persons submitting this questionnaire in connection 11.In what capacity will you be employed? (e.g., Clerk, Escrow Officer, Manager, Officer, Director, etc.)12.Do you expect to be a party to, or broker or salesman in connection with escrows conductedby the escrow company which is employing you? Yes No If the answer is "Yes", give details: American LegalNet, Inc. www.FormsWorkFlow.com Insert Full Name Insert Licensee of Individual: (Company Name): 5 This statement will be considered confidential information and will be filed and maintained as part of the confidential records not subject to public inspection. VERIFICATION I, the undersigned, state that I am the person named in the foregoing Statement of Identity and Questionnaire; that I have read and signed said Statement of Identity and Questionnaire and know the contents thereof, including all exhibits attached thereto, and that the statements made therein, including any exhibits attached thereto, are true, and that I have not omitted any information needed to make this document true. This verification may be made either before a Notary Public or as a declaration under penalty of perjury. This form MUST be executed before a Notary Public if it is executed OUTSIDE the State of California. I certify/declare under penalty of perjury that the foregoing is true and correct. Executed at (City) (County) (State) this day of , 20. (Print Name) (Signature of Individual) State of ) County of ) Date , 20 at (Signature of Individual) Subscribed and sworn to before me , 20 Notary Public in and for said County and State American LegalNet, Inc. www.FormsWorkFlow.com 6 DBO Collects and Uses Personal Information: The DBO collects the information requested on this form as authorized by the California Financial Code sections 17209.1, 17414.1, and 22101(b). qualifications associated with an applicant or a licensee and to conduct criminal history record checks. Use of the personal Information DBO collects is subject to limitations contained in the Information Practices Act of 1977 and other applicable state and federal laws. Providing Personal Information Is Mandatory: When providing information or documents, please do not include unrequested personal information such as a Social Security number, DBO May Disclose Your Personal Information: We may share your personal information State and Federal Regulators, law enforcement agencies, other federal, state or local law enforcement agencies, or a self-regulatory organization as authorized by law. Your personal information may also be disclosed: In response to a Public Records Act request, as allowed by the Information PracticesAct.To another governmental agency as required by state or federal law.In response to a court order or administrative order, a subpoena or a search warrant.Your Access to Your Personal Information: You may review the records maintained by DBO that contain your personal information. To request access, contact: DBO Privacy Officer, 1515 K Street, Sacramento, CA 95814, (866) 275-2677. American LegalNet, In