IMPORTANT NOTICE: Completion of this form is necessary to accomplish the requirements outlined in [765 ILCS 86]. Disclosure of this information is REQUIRED. Failure to provide any information will result in this form not being processed. Submission of false information may subject the affiant to prosecution under applicable perjury statutes. This form has been approved by the Agency Forms Coordinator. LAND SALES ANNUAL ENCUMBRANCE REPORT --- B STATE OF ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION Division of Professional Regulation 320 West Washington Street Springfield, IL 62786 SUBDIVIDER: REGISTRATION NUMBER: 1. CURRENT ENCUMBRANCE BALANCE: 2. NAME AND ADDRESS OF SECURED CREDITOR: 3. TYPE OF ENCUMBRANCE: 4. DATE OF ENCUMBRANCE: 5. DATE OF AMENDMENTS: 6. IF ANSWER IS "NO" TO THE FOLLOWING, PROVIDE DETAILS ON SEPARATE SHEET. 7. IF ANSWER IS "NO" TO THE FOLLOWING, PROVIDE DETAILS ON Are interest payments current? Yes No SEPARATE SHEET. Are principal payments current? Yes No 8. EXPLAIN ANY CHANGES IN FINANCING: AFFIDAVIT The following signatory does swear the information contained in this report is true and correct and constitutes a complete statement of matter to which it relates. Signature: ____________________________________________ Please type name and title: ____________________________________________ ____________________________________________ State of _______________________ County _______________________ Subscribed and sworn to before me this _________________ day of __________________________, 20____________. NOTARY SEAL Commission Expires: __________________ _________________________________________ (Notary Public Signature) SUBMISSION OF A FALSE AFFIDAVIT MAY SUBJECT THE AFFIANT TO PROSECUTION UNDER APPLICABLE PERJURY STATUTES IL505-0443 (Rev. Apr 2009) American LegalNet, Inc. www.FormsWorkflow.com