APPLICATION FOR LICENSE AS A LOAN BROKER State Form 38168 (R8 / 6-08) / Form LB 1 Approved by State Board of Accounts, 2008 Explanation and Instructions Before completing this Application for License as a Loan Broker, you should read and be familiar with the Indiana Loan Broker Act, codified in Indiana Code 23-2-5 and the rules relating to the Act which are contained in Indiana Administrative Code 710 IAC 1-22. You may access the statutes and rules through the Division’s website: www.sos.IN.gov/securities. This properly completed application form must be accompanied by: • $400 non-refundable application fee, $200 for each ultimate equitable owner, payable to: “Indiana Secretary of State,” plus $32.25 for an FBI criminal background check for each individual listed in Schedule A, Section 2. • Properly completed Ultimate Equitable Owner Information Form (State Form 53271/Form LB 2) for each ultimate equitable owner; • Properly completed Branch Office Notification Form (State Form 53264/Form LB 3) for each branch office located, or engaging in origination activities in Indiana (if applicable); • Properly completed Application for Registration as a Principal Manager or an Originator (State Form 49718/Form LB 4) for the principal manager listed in Section 1(H), if applicable; • Original $50,000 Surety Bond • FBI fingerprint card for each individual listed in Schedule A, Section 2. • Any additional documentation needed to answer questions. • DO NOT include the instructions (pages 1-4 of this application). Before a license may be issued each of the individuals listed on Schedule A of this application and the principal manager listed in Section 1(H) must undergo an FBI criminal background check. (NOTE: The license will not be issued until all required FBI criminal background checks have been received and reviewed by the Secretary of State, Securities Division.) A PERSON WHO KNOWINGLY FILES WITH THE COMMISSIONER ANY DOCUMENT OR STATEMENT THAT CONTAINS A FALSE REPRESENTATION OF A MATERIAL FACT IS SUBJECT TO THE LICENSE BEING DENIED, SUSPENDED, OR REVOKED; THE IMPOSITION OF A CIVIL PENALTY OF UP TO $10,000 PER VIOLATION; AND CHARGED WITH A CLASS C FELONY WHICH IS PUNISHABLE BY A FINE UP TO $10,000 PER VIOLATION AND UP TO EIGHT (8) YEARS OF IMPRISONMENT. If the space provided for any answer is inadequate, complete your answer on a separate sheet, specifying the question to which it relates and attach this sheet to the application. For each additional sheet you provide, sign and list the applicant’s name. Submit your properly completed application along with any supporting documentation to the following address: Indiana Secretary of State Securities Division 302 W. Washington St., Room E – 111 Indianapolis, Indiana 46204 A. GENERAL INSTRUCTIONS 1. TERMS USED – See the following Explanation of Terms section regarding italicized words/phrases used throughout State Form 38168/ Form LB 1. 2. AMENDMENTS – The applicant must notify the Division as required by Indiana Code § 23-2-5-10(i) of a change in any information contained in this form by submitting amendments using State Form 38168/Form LB 1 within two business days of the change. Complete the name of the applicant, the license number, and circle (or otherwise identify) and complete item(s) being amended, and complete Section 9. For name or entity type changes, submit along with this form, an original bond or bond rider that reflects the new information to the Indiana Secretary of State, Securities Division. 3. SURRENDER / CANCEL– When an applicant decides to cease operations under the license, use State Form 38168/Form LB 1 to notify the Secretary of State, Securities Division by checking the “Surrender/Cancel” box and completing only Sections 1(A)and 9, and return the form along with the original license to the Securities Division. 4. PRINT OR TYPE: Illegible or incomplete applications will be returned. State Form 38168 (R8 / 6-08) / Form LB 1 Page 1 of 11 American LegalNet, Inc. www.FormsWorkflow.com B. SECTION INSTRUCTIONS Section 1 – NAME AND CONTACT INFORMATION: Complete each line, providing the exact name, principal office address, mailing address, if different, and telephone numbers of applicant. The name on the license will appear exactly as reported in 1(A) and 1(C). The license and all correspondence will be sent to the address reported in 1(E). If an applicant answers Yes to question 1(I), the applicant will need to complete a Branch Office Notification Form (State Form 53264/Form LB 3) for each branch office located, or engaging in origination activities in Indiana. The individual listed as the principal manager in Section 1(H) must be registered with the Indiana Secretary of State, Securities Division by filing a properly completed Application for Registration as a Principal Manager or an Originator (State Form 49718/Form LB 4). Section 2 – CONTACT INFORMATION FOR APPLICANT: Complete each line. The individual listed as the contact employee must be authorized to receive all compliance and licensing information, communication, and mailings, and be responsible for disseminating it within the applicant’s organization. Section 3 – BUSINESS ENTITY INFORMATION: Check the appropriate box and provide the following: A. If the applicant is a corporation, enclose a copy of the Articles of Incorporation, including amendments, as well as a Certificate of Good Standing issued by the domestic state, if other than Indiana. B. If the applicant is a limited liability company (LLC), enclose a copy of the Articles of Organization and operating agreement as well as a Certificate of Good Standing issued by the domestic state, if other than Indiana. C. If the applicant is a partnership of any form, enclose a copy of the partnership agreement. If the applicant is a limited partnership, enclose a Certificate of Good Standing issued by the domestic state, if other than Indiana. When you submit this application you are affirming that: A. all information is true and complete; B. a business entity required to file reports with the Business Services Division of the Secretary of State’s office is current in the filing of the reports; and C. a business entity formed in a state other than Indiana has properly qualified to do business in Indiana. You may want to confirm the status of your business entity by contacting the Indiana Secretary of State, Business Services Division, at www.sos.IN.gov/business or (317) 232.6576. Section 4 – CONSENT TO SERVICE OF PROCESS: The Loan Broker Act provides that legal documents relating to proceedings against a loan broker arising from the conduct of the loan broker business or out of violation of the laws of Indiana be served upon the Secretary of State, Securities Division. After accepting service of the documents, the Secretary of State, Securities Division, will forward the documents to the agent listed in this section. The agent may be any individual or company. Section 5 – PRINCIPAL MANAGERS & ORIGINATORS: Every loan broker is required to have at least one registered principal manager at the principal branch office. If the loan broker has branch offices, a registered principal manager is required for each branch office. Each individual engaged in origination activities or serving as a principal manager for the loan broker must be registered with the Secretary of State, Securities Division by filing an Application for Registration as a Principal Manager or an Originator (State Form 49718/Form LB 4). In this section list the name, title, and registration number for each individual employed by the loan broker engaged in origination activities or serving as a principal manager. Section 8 – DISCLOSURES: If the answer is “YES” to any of the questions, provide complete details of all events or proceedings in an attachment, including as applicable; name and location of court, docket or case number, and status and summary of event or proceeding; copies of applicable charge(s), order(s), and/or consent agreement(s). Refer to the explanation of terms section of the instructions for explanations of italicized terms. Remember to file updates of these disclosures as needed. Section 9 – VERIFICATION By signing the verification, the loan broker is affirming that the application is true and complete, that no one specified in 9(A) has been convicted of a felony within the previous five (5) years or a crime of fraud or deceit within the previous ten (10) years, and that all principal managers and originators are properly registered. If a member of the management, principal manager, or an originator has been convicted of a felony within the previous five (5) years or a crime of fraud or deceit in the previous ten (10) years, this information must be disclosed by attaching additional pages listing the offense, cause number, date of conviction, and the court in which the individual was convicted. The Commissioner may deny a license based on this information. State Form 38168 (R8 / 6-08) / Form LB 1 Page 2 of 11 American LegalNet, Inc. www.FormsWorkflow.com B. SECTION INSTRUCTIONS CONTINUED Schedule A – ULTIMATE EQUITABLE OWNERS AND EXECUTIVE OFFICERS All applicants must complete Schedule A. List all of the applicant’s ultimate equitable owners and executive officers. Complete each column. Each ultimate equitable owner listed must complete the Ultimate Equitable Owner Information Form (State Form 53271/Form LB 2). If the ultimate equitable owner is to engage in origination activities, the individual must apply for registration on the Application for Registration as a Principal Manager or an Originator (State Form 49718/Form LB 4). Schedule B – AMENDMENTS TO SCHEDULE A Use this form to amend information provided on Schedule A of State Form 38168/Form LB 1. Refer to Schedule A for the specific instructions. Complete each column. SURETY BOND INFORMATION: A loan broker must maintain a $50,000 surety bond in the full, legal name of the loan broker for the full licensing period. The name on the bond must be the exact name on lines 1(A) and 1(C) of this application. The bond must be signed by a person on behalf of the loan broker. Attach the original bond and power of attorney to this application. The power of attorney is issued by the surety bond company. It authorizes the agent of the surety bond company to issue bonds on behalf of the company. All bond documents must be original documents. The Secretary of State, Securities Division, will not accept faxed bond documents. If this is a renewal application, a bond rider or bond continuation certificate is acceptable to demonstrate that the bond remains in effect. C. EXPLANATION OF TERMS – The following terms are the italicized terms used throughout State Form 38168/Form LB 1 and have the following meaning. 1. GENERAL APPLICANT – The loan broker applying or amending information on this form. The only instance in which the applicant is an individual is in the case of a sole proprietorship. CONTACT EMPLOYEE – The individual authorized to receive all compliance and licensing information, communications, and mailings, and be responsible for disseminating it within the applicant’s organization. CONTROL – The power, directly or indirectly, to direct the management or policies of an entity, whether through ownership of securities, by contract, or otherwise. Any person that (1) directly or indirectly has the right to vote 10% or more of a class of a voting security or has the power to sell or direct the sale of 10% or more of a class of voting securities; (2) in the case of an LLC, Managing Member; or (3) in the case of a partnership, has the right to receive upon dissolution, or has contributed, 10% or more of the capital, is presumed to control that company. JURISDICTION – A state, the District of Columbia, the Commonwealth of Puerto Rico, or any subdivision or regulatory body thereof. ORIGINATOR – A person engaged in origination activities. ORIGINATION ACTIVITIES – Communication with or assistance of a borrower or prospective borrower in the selection of loan products or terms. PERSON – An individual, a partnership, a trust, a corporation, a limited liability company, a limited liability partnership, a sole proprietorship, a joint venture, a joint stock company, or another group or entity, however organized. PRINCIPAL MANAGER – The individual responsible for the supervision and management of the employees and business affairs of the licensee at a specific office location. SETTLEMENT SERVICES – The same as defined in federal Real Estate Settlement Procedures Act (RESPA) 12 U.S.C. Sec. 2601 et seq., Regulation X, 24 C.F.R. Part 3500 et seq. ULTIMATE EQUITABLE OWNER – A person who, directly or indirectly, owns or controls ten percent (10%) or more of the equity interest in a loan broker licensed or required to be licensed under Indiana Code 23-2-5, regardless of whether the person owns or controls the equity interest through one (1) or more other persons or one (1) or more proxies, powers of attorney, contracts, or other arrangements. 2. FOR THE PURPOSE OF SECTION 8 CHARGED – Being accused of a crime in a formal complaint, information, or indictment (or equivalent formal charge). CONTROL AFFILIATE – A partnership, corporation, trust, LLC, or other organization that directly or indirectly controls, or is controlled by, the applicant. ENJOINED – Includes being subject to a mandatory injunction, prohibitory injunction, preliminary injunction, or a temporary restraining order. FELONY – An offense punishable by a sentence of at least one (1) year imprisonment and/or a fine of at least $1,000. FINANCIAL SERVICES OR FINANCIAL SERVICES RELATED – Pertaining to securities, commodities, banking, insurance, consumer lending, or real estate (including, but not limited to; acting as or being associated with a bank or savings association, credit union, mortgage lender, loan broker, real estate salesperson or agent, closing agent, title company, or escrow agent). State Form 38168 (R8 / 6-08) / Form LB 1 Page 3 of 11 American LegalNet, Inc. www.FormsWorkflow.com C. EXPLANATION OF TERMS CONTINUED FOREIGN FINANCIAL REGULATORY AUTHORITY – Includes (1) a financial services authority of a foreign country; (2) other governmental body empowered by a foreign government to administer or enforce its laws relating to the regulation of financial services or financial services-related activities; and (3) a foreign membership organization, a function of which is to regulate the participation of its members in financial services activities listed above. FOUND – Includes adverse final actions, including consent decrees in which the respondent has neither admitted nor denied the findings, but does not include agreements, deficiency letters, examination reports, memoranda of understanding, letters of caution, admonishments, and similar informal resolutions of matters. INVOLVED – Doing an act or omission or aiding, abetting, counseling, commanding, inducing, conspiring with or failing to reasonably supervise another in doing an act or omission. MISDEMEANOR – An offense punishable by a sentence of less than one (1) year imprisonment and/or a fine of less than $1,000. ORDER – A written directive issued pursuant to statutory authority and procedures, including orders of denial, suspension, or revocation; does not include special stipulations, undertakings or agreements relating to payments, limitations on activity or other restrictions unless they are included in an order. PROCEEDING – Includes a formal administrative or civil action initiated by a governmental agency, self-regulatory organization or a foreign financial regulatory authority; a felony criminal indictment or information (or equivalent formal charge); or a misdemeanor criminal information (or equivalent formal charge). The term does not include other civil litigation, investigations, or arrests or similar charges affected in the absence of a formal criminal indictment or information (or equivalent formal charge). REST OF PAGE INTENTIONALLY LEFT BLANK State Form 38168 (R8 / 6-08) / Form LB 1 Page 4 of 11 American LegalNet, Inc. www.FormsWorkflow.com Todd Rokita Indiana Secretary of State Securities Division 302. W. Washington Street, E-111 Indianapolis, Indiana 46204 (317) 232-6681 APPLICATION FOR LICENSE AS A LOAN BROKER State Form 38168 (R8 / 6-08) / Form LB 1 Approved by State Board of Accounts, 2008 Date (MM/DD/YYYY): License Number Information (if applicable). Use additional sheets if necessary. License # Jurisdiction License # Jurisdiction License # Jurisdiction License # Jurisdiction NEW APPLICATION SURRENDER/CANCEL AMENDMENT To amend, circle or identify item(s) being amended RENEWAL APPLICATION 1. NAME AND CONTACT INFORMATION: (A) Full name of applicant (sole proprietors provide last, first, and full middle name): (B) IRS Employer Identification Number (Social Security Number is allowed for sole proprietorship) (C) (1) Name under which business primarily is or will be conducted, if different from item 1(A): (2) List any other name(s) by which the applicant conducts or will conduct business. (use additional sheets as needed) 1. Name Jurisdiction 2. Name Jurisdiction 3. Name Jurisdiction 4. Name Jurisdiction (D) FOR AMENDMENTS ONLY: If this filing reports the applicant’s name has changed, specify whether the name change is of the applicant name 1(A) or business name 1(C)(1). Enter the previous name in item 1(A) and current applicant name here: Or new business (trade/dba) name here: (E) Principal Office Address: (Do not use a P.O. Box) Number & Street City State/Province & Country Zip+4/Postal Code (F) Mailing Address, if different from Principal Office address: P.O. Box or Number & Street City State/Province & Country Zip+4/Postal Code (G) Telephone Numbers and Website: Business Phone Fax Line Website Address Email address (H) Name of Principal Manager at location listed in 1(E): Last Name First Name Middle Name Registration # (I) Other than the offices in 1(E), does the applicant conduct business with consumers through branch offices or other business locations? YES NO (Branch offices or other business locations must be reported. Use State Form 53264/Form LB 3) State Form 38168 (R8 / 6-08) / Form LB 1 Page 5 of 11 American LegalNet, Inc. www.FormsWorkflow.com Applicant full legal name: ________________________________________________ 2. CONTACT INFORMATION FOR APPLICANT: (A) Contact Employee: Name and Title Business Phone Fax Line P.O. Box or Number & Street City State/Province and Country Zip+4/Postal Code Fax Line Email address City State/Province and Country Zip+4/Postal Code Business Phone Fax Line Email address City State/Province and Country Zip+4/Postal Code (B) Employee authorized to respond to consumer complaints: Name and Title Business Phone P.O. Box or Number & Street (C) Records Custodian: Records Custodian Name P.O. Box or Number & Street Email address 3. BUSINESS ENTITY INFORMATION: (A) Indicate legal status of applicant. Corporation Sole Proprietorship (B) Applicant’s fiscal year end (MM/DD): Partnership Limited Liability Company Other (specify) ____________________ (C) If other than a sole proprietorship, indicate date and place applicant obtained its legal status (i.e. state or country where incorporated, where partnership agreement was filed, or where applicant entity was formed): State/Province & Country of formation Date of Formation (MM/DD/YYYY) 4. CONSENT TO SERVICE OF PROCESS: (NAME OF LOAN BROKER BUSINESS)_______________________________________________________________, Organized under the laws of the State of ___________________________, appoints the Secretary of State of Indiana, and the successors in such office, its attorney in the State of Indiana upon whom may be served any notice, process, or pleading in any action or proceeding against the loan broker arising out of, or in connection with the conduct of a loan broker business or out of violation of the laws of Indiana; and the loan broker does hereby consent that any such action or proceeding against it may be commenced in any court of competent jurisdiction and proper venue within Indiana by service of process upon said agent as if the undersigned was organized or created under the laws of Indiana and has lawfully been served with process in Indiana. IT IS REQUESTED THAT A COPY OF ANY NOTICE, PROCESS, OR PLEADING SERVED HEREUNDER BE MAILED TO: Name of Agent Street Address of Agent City State Zip+4/Postal Code Signature Title State Form 38168 (R8 / 6-08) / Form LB 1 Date (MM/DD/YYYY) Page 6 of 11 American LegalNet, Inc. www.FormsWorkflow.com Applicant full legal name: ________________________________________________ 5. PRINCIPAL MANAGER & ORIGINATORS: TITLE FULL LEGAL NAME REGISTRATION # (Last Name, First Name, Middle Name) 6. YES NO YES (A) Will applicant engage in any non-loan-brokerage business? NO YES NO If “yes” provide the names under which business will be conducted: (B) Will applicant occupy or share space with any person(s)? If “yes,” provide the name(s) and description of business type of the other person(s): 7. Does the applicant either directly or indirectly control or is applicant under common control with, any person that is engaged in the business of a mortgage lender, loan broker, real estate appraiser, real estate broker, or providers of other settlement services? If yes, complete information below for each relationship. In the “Control Relationship” Column”, enter “S” if the applicant controls the entity (subsidiary) and “A” if the applicant is under common control with the entity (affiliate). Attach additional sheets as necessary. Name of Partnership, Corporation, or Organization Number and Street City State/ Province Zip + 4/ Postal Code Control Relationship Briefly describe control relationship(s), including an organizational chart which shows the relationship(s). Use additional sheets for comments if necessary. State Form 38168 (R8 / 6-08) / Form LB 1 Page 7 of 11 American LegalNet, Inc. www.FormsWorkflow.com Applicant full legal name: ________________________________________________ 8. DISCLOSURES: Criminal Disclosure (A) In the past five (5) years has the applicant or an ultimate equitable owner ever: (1) been convicted of or pled guilty or nolo contendere (“no contest”) in a domestic, foreign, or military court to any felony? (2) been charged with any felony? (B) In the past ten (10) years has the applicant or an ultimate equitable owner: (1) been convicted of or pled guilty or nolo contendere ("no contest") in a domestic, foreign, or military court to a crime involving: any financial services or a financial services-related business; any fraud, false statements, or omissions; any theft or wrongful taking of property; bribery; perjury; forgery; counterfeiting; extortion; or a conspiracy to commit any of these offenses? (2) been charged with a crime specified in 8(B)(1) Regulatory Action Disclosure (C) In the past ten (10) years, has any state or federal regulatory agency or foreign financial regulatory authority: (1) found the applicant or an ultimate equitable owner to have made a false statement or omission or been dishonest, unfair or unethical? (2) found the applicant or an ultimate equitable owner to have been involved in a violation of any financial services-related regulation(s) or statute(s)? (3) found the applicant or an ultimate equitable owner to have been a cause of a financial services-related business having its authorization to do business denied, suspended, revoked or restricted? (4) entered an order against the applicant or an ultimate equitable owner in connection with a financial services-related activity? (5) denied, suspended, or revoked the applicant’s or an ultimate equitable owner’s registration or license or otherwise, by order, prevented it from associating with a financial services-related business or restricted its activities? (D) Is the applicant or an ultimate equitable owner now the subject of any regulatory proceeding that could result in a "yes" answer to any part of 8(C)? Civil Judicial Disclosure (F) (1) Has any domestic or foreign court: (a) in the past ten (10) years enjoined the applicant or an ultimate equitable owner in connection with any financial services-related activity? (b) in the past ten (10) years found the applicant or an ultimate equitable owner to be in violation of any financial services-related statute(s) or regulation(s)? (c) in the past ten (10) years dismissed, pursuant to a settlement agreement, a financial servicesrelated civil action brought against the applicant or an ultimate equitable owner by a State or foreign financial regulatory authority? (2)Is the applicant or an ultimate equitable owner named in any pending financial services-related civil action that could result in a "yes" answer to any part of 8(F)(1)? Financial Disclosure (G) In the past ten (10) years has the applicant or an ultimate equitable owner been a mortgage lender or a loan broker or an ultimate equitable owner of a mortgage lender or a loan broker that has been the subject of a bankruptcy petition? (H) Has a bonding company ever denied, paid out on, or revoked a bond for the applicant? YES NO Yes No Yes No Yes No 9. VERIFICATION: I, _____________________________________, do solemnly swear or affirm under the penalties of perjury that: A. none of the applicant’s equitable owners, directors, managers, officers, or originators have been convicted in any jurisdiction of a felony within the previous five (5) years or a crime involving fraud or deceit in the previous ten (10) years other than that which is disclosed on this application or documents attached hereto; B. each individual conducting origination activities on behalf of the applicant is properly registered with the Indiana Secretary of State, Securities Division. C. this business entity is properly registered with the Indiana Secretary of State, Business Services Division D. the foregoing bond was executed for the uses and purposes therein set forth; and E. the information appearing in this application form and the attached documents hereto is true, accurate, and complete to the best of my knowledge; Signature Title Date (MM/DD/YYYY) Schedule A (ultimate equitable owners) must be completed as part of all applications. Amendments to schedules A must be provided on Schedule B as changes occur. State Form 38168 (R8 / 6-08) / Form LB 1 Page 8 of 11 American LegalNet, Inc. www.FormsWorkflow.com Schedule A ULTIMATE EQUITABLE OWNERS AND EXECUTIVE OFFICERS 1. 2. Applicant full legal name Date (MM/DD/YYYY) Use Schedule A only in initial or renewal applications to provide information on the ultimate equitable owners and executive officers of the applicant. File all amendments on Schedule B. Complete each column. List below the names of: (a) each ultimate equitable owner (b) each executive officer, including President, Chief Executive Officer, Chief Financial Officer, Chief Operations Officer, Chief Legal Officer, Chief Compliance Officer, Director, and individuals with similar status or functions; 3. Complete the “Title or Status” column by entering board/management titles; status as a partner, trustee, sole proprietor, or shareholder; and for shareholders, the class of securities owned (if more than one is issued). 4. Each ultimate equitable owner will need to complete the State Form 53271/Form LB 2. FULL LEGAL NAME Title or Status (individuals: Last Name, First Name, Middle Name) State Form 38168 (R8 / 6-08) / Form LB 1 Percent Ownership Page 9 of 11 American LegalNet, Inc. www.FormsWorkflow.com Schedule B AMENDMENTS TO SCHEDULE A 1. 2. 3. 4. Applicant full legal name Date (MM/DD/YYYY) This Schedule is used to amend Schedule A of State Form 38168/Form LB 1. Refer to schedule A for specific instructions for completing this Schedule B. Complete each column. In the Type of Amendment column, indicate “A” (addition), “D” (deletion), or “C” (change in information about the same person). List below all changes to Schedule A (ULTIMATE EQUITABLE OWNERS AND EXECUTIVE OFFICERS): For each ultimate equitable owner added or change in information, complete the State Form 53271/Form LB 2. FULL LEGAL NAME Type of Title or Status Percent (individuals: Last Name, First Name, Middle Name) Amendment Ownership State Form 38168 (R8 / 6-08) / Form LB 1 Page 10 of 11 American LegalNet, Inc. www.FormsWorkflow.com Todd Rokita Indiana Secretary of State Securities Division 302. W. Washington Street, E-111 Indianapolis, Indiana 46204 (317) 232-6681 LOAN BROKER BOND State Form 53305 (6-07) BOND NUMBER VALIDATION DATES KNOW ALL MEN BY THESE PRESENTS: FROM: That we, ___________________________________, of______________________________ (Name of Loan Broker Business) (City) SURETY PHONE NUMBER TO:12/31/ in the state of ______________________________ , and _____________________________ a corporation organized and existing (Name of Surety) under and by virtue of the laws of the State of______________, and duly authorized to transact the business of indemnity and suretyship in the State of Indiana, for the use and benefit of all persons damaged by the breach of any of the conditions of this obligation, in the sum of Fifty Thousand ($50,000) Dollars, lawful money of the United States for the payment of which sum, will and truly to be made, we bind ourselves, our heirs executors, administrators, successors and assigns, jointly and severally, firmly by these presents. THE CONDITIONS OF THE ABOVE OBLIGATION ARE SUCH THAT: WHEREAS, the above bounden Loan Broker has made application to the Securities Commissioner of the State of Indiana for license as a loan broker under the provision of IC 23-2-5 and is required by the provisions of said Law to furnish a surety bond in the sum above named, conditioned as herein set forth. NOW, THEREFORE, if the said Loan Broker shall faithfully comply with the provisions of IC 23-2-5 and shall pay to any person entitled thereto all damages as may be caused to such person by the failure of the Loan Broker to faithfully comply with the provisions of said Act; and if said Loan Broker shall pay to any person entitled thereto all damages as may be caused to any person together with all penalties provided by IC 23-2-5-15 then this obligation shall be void; otherwise it shall remain in full force and effect. This bond is subject to the following provisions: 1. Any person who sustains such damages as covered by this bond may bring an action upon this bond; provided, however, that the aggregate liability of the said Surety to all such persons shall, in no event, exceed the amount of the bond. 2. This bond shall be and remain in full force and effect and run concurrent with the license period and any renewal thereof, until it is terminated by the said Surety giving written notice both to the said Loan Broker and the Securities Commissioner of Indiana thirty (30) days prior to the effective date thereof, of its intention to terminate its liability under this bond or until the license of said Loan Broker as such loan broker is terminated either by expiration without renewal or by revocation for any cause. 3. Every person who has a cause of action under IC 23-2-5 may bring action upon this bond to enforce any liability on the bond providing, however, that no suit on this bond may be maintained to enforce any liability on this bond unless brought within two (2) years after the act upon which it is based. IN WITNESS WHEREOF, the parties hereto have set their hand and seals this __________________________ day of____________________________, ________. Surety By: ______________________________________ _______ its: State Form 38168 (R8 / 6-08) / Form LB 1 Loan Broker By: _____________________________________ _______ its: Page 11 of 11 American LegalNet, Inc. www.FormsWorkflow.com