FOR OFFICIAL USE ONLY ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION DIVISION OF REAL ESTATE 320 WEST WASHINGTON STREET SPRINGFIELD, ILLINOIS 62786 LAND SALES REGISTRATION ACT OF 1999 APPLICATION FOR EXEMPTION It is unlawful for any person to engage in the business of selling land that is located outside the State of Illinois to any individual located in Illinois without a certificate of registration or a letter of exemption as set forth in Section 5-15 of the Land Sales Registration Act of 1999 [765 ILCS 86]. This form has been approved by the Agency Forms Coordinator. INSTRUCTIONS Complete all sections of this form, attach any documentation supporting the exemption request, and include a non-refundable application processing fee of $250.00. All checks should be made payable to the Illinois Department of Financial and Professional Regulation. DEVELOPER NAME OF DEVELOPER: F.E.I.N. OR SOCIAL SECURITY NUMBER: ADDRESS OF DEVELOPER: TELEPHONE NUMBER: ) ( ADDRESS OF SUBDIVISION: Street City State Zip Code NAME OF SUBDIVISION: Street City State Zip Code CHECK THE APPROPRIATE EXEMPTION AND PROVIDE SUPPORTING DOCUMENTATION VERIFYING SUCH INFORMATION. A. The subdivision was purchased for own account in a single or isolated transaction. B. The subdivision consists of fewer than 25 separate lots, parcels, units or interests. (Attach plat map.) C. The subdivision houses a commercial or industrial building, shopping center, house, apartment house, condominium structure or town house, or there is a legal obligation on the part of the seller to construct such a building within 2 years from the date of disposition. (Attach a copy of the sales contract.) D. The subdivision will be sold for industrial, commercial, or institutional purposes. E. The subdivision consists of cemetery lots or interests. F. The subdivision will be disposed of to 10 or fewer persons. G. The subdivision consists of lots or parcels of 20 or more acres, unconditionally, or of 10 or more acres with free and ready access leading to county-maintained roads. (Attach plat map.) Signature of Authorized Representative of Developer Date PRINTED NAME IL 505-0516 (Rev. June 2014) American LegalNet, Inc. www.FormsWorkFlow.com CHECK ALL THAT APPLY STATE OF ILLINOIS LAND SALES REGISTRATION ACT OF 1999 REGISTRATION FEES 1. INITIAL REGISTRATION : FEE a) SUBDIVISION/DEVELOPER $ 1,500.00 2. AMENDMENT: a) ADDING LOTS OR OTHER CONTIGUOUS PROPERTY $ 750.00 b) ANY OTHER AMENDMENT TO AN EXISTING REGISTRATION $ 150.00 4. RENEWAL: a) SUBDIVISION/DEVELOPER $ 750.00 b) LATE RENEWAL (received by DFPR after June 30 due date) $ 50.00 5. MISCELLANEOUS: a) APPLICATION FOR EXEMPTION $ 250.00 b) ROSTER OF REGISTRANTS $ 10.00 c) APPLICATION FOR RESTORATION OF REGISTRATION $ 250.00 $ _____________ Check No. _____________ TOTAL AMOUNT ENCLOSED NOTE: Please return the completed form along with a check made payable to the IDFPR - Division of Real Estate for total amount due. Please remit to: Illinois Department of Financial and Professional Regulation Division of Real Estate Attn: Timeshare/Land Sales 320 West Washington Street Springfield, Illinois 62786 IL 505-0698 (Rev. June 2014) American LegalNet, Inc. www.FormsWorkFlow.com