Illinois Secretary of State Securities Department Loan Broker Borrower Statement 421 E. Capitol Ave., 2nd Floor Springfield, IL 62701 · 217-782-2256 69 W. Washington St., Ste. 1220 Chicago, IL 60602 · 312-793-3384 800-628-7937 By completing this statement you will be assisting the Illinois Securities Department with the inquiry of a Loan Broker. The information received will enable the Securities Department to conduct a more accurate inquiry. BORROWER INFORMATION: Name: Age: Address: City: Home Telephone Number: Please indicate the most convenient day to be contacted: Monday Tuesday Wednesday Thursday Friday Please indicate the most convenient time and place to be contacted: Work (indicate time): Home (indicate time): INQUIRY REFERENCE TO: Name of Loan Broker: Address: City: Telephone Number: State: Email/Internet Address: ZIP: State: Work Telephone Number: ZIP: Name, Address, Telephone Number and Email Address (if known) of person you dealt with: Title or Position the person stated he/she held: TRANSACTION INFORMATION: Describe how you contacted or were contacted by the Loan Broker: Describe the loan you hoped to obtain and why you wanted it: Did the Loan Broker promise to obtain this loan for you or to help you obtain this loan? Yes No Printed by authority of the State of Illinois. November 2015 -- 100 -- SEC 322.1 American LegalNet, Inc. www.FormsWorkFlow.com Did you sign a contract for the Loan Broker's services? Yes (indicate date you signed the contract): No Before you signed a contract for the Loan Broker's services, or before you paid anything for the Loan Broker's services (whether or not you had a signed contract for those services), did the Loan Broker provide you with a written description of the services to be performed and the circumstances under which the Loan Broker would be entitled to keep or receive a fee? Yes (indicate when this was provided to you): No Did you pay a fee to the Loan Broker before you received a binding commitment from a lender to make the loan? Yes (indicate if amount paid was solely intended to reimburse the Loan Broker for out-of-pocket expenses): No If yes, amount of fee: Date paid and form of payment (be specific): MISCELLANEOUS: Have you filed an inquiry or complaint with the company, the Better Business Bureau or any other person or governmental agency? Yes No If yes, indicate Name, Address and Telephone Number of Person or Agency, and Date: What, if any, action has been taken? Have you obtained private legal counsel? Yes No If yes, indicate Name, Business Address and Telephone Number of Attorney: ATTACH COPIES OF ANY DOCUMENTS REGARDING THIS MATTER. (Include the front and back of all canceled checks, or other evidences of payment of the Loan Broker's fee.) Are you willing to be interviewed by a Securities Department investigator? Yes No Are you willing to testify if formal proceedings are commenced? Yes No DESCRIBE IN DETAIL ANY OTHER INFORMATION THAT MAY HELP THE SECURITIES DEPARTMENT UNDERSTAND THE AGREEMENT AND ANY DISCUSSION BETWEEN YOU AND THE LOAN BROKER. IF MORE SPACE IS NEEDED, PLEASE ATTACH ADDITIONAL SHEETS: Signature of Borrower Date American LegalNet, Inc. www.FormsWorkFlow.com