BRANCH OFFICE NOTIFICATION State Form 53264 (R2 / 4-08) / Form LB 3 Explanation and Instructions Pursuant to Indiana Admin. Code 710 IAC 1-22-8 an applicant must file this Branch Office Notification form (State Form 53264/FormLB 3) with the Secretary of State, Securities Division for each of the loan broker’s branch offices that are located or engaging in origination activities in Indiana. The State Form 53264/Form LB 3 may accompany a new Application for License as a Loan Broker (State Form 38168/Form LB 1) or may be filed when a new branch office is opened. If the branch office is a new branch office, the loan broker must file a Branch Office Notification Form (State Form 53264/Form LB 3) with the Securities Division before any origination activities may be conducted out of the branch office. 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 this properly completed form 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 the State Form 53264/Form LB 3. 2. AMENDMENTS – The applicant must file with the Secretary of State, Securities Division, as required by Indiana Code § 23-2-5-10(i) a change in any information contained in this form by submitting amendments using State Form 53264/Form LB 3 within two business days of the change. When making amendments to an existing branch office, provide the applicant’s name, the license number, check the “amendment” box on line (1), provide all previous information in items (2a) through (6a), complete only the information that is being amended in item(s) (2b) through (6b) or (7) through (9), and complete Section 10. 3. CEASING OPERATIONS– When an applicant decides to cease operations at one or more branch offices, use the State Form 53264/Form LB 3 to notify the Secretary of State, Securities Division by providing the license number, checking the “ceasing operations” box, and completing only Sections (2a) and (10). Submit a separate State Form 53264/Form LB 3 for each branch office that is ceasing operations. Use State Form 38168/Form LB 1 to notify the Secretary of State, Securities Division if the entire company will cease operations under the license. 4. OTHER ITEMS A. The principal manager identified in Section (6), must be registered with the Secretary of State, Securities Division. To become registered as a principal manager, an individual must submit an Application for Registration as a Principal Manager or as an Originator (State Form 49718/Form LB 4) with the Secretary of State, Securities Division. (NOTE: Pursuant to Indiana Code § 23-2-5-20.5(b) a loan broker shall not operate any branch office of a loan brokerage business without employing a registered principal manager at that location) B. All employees conducting origination activities at the branch office must be registered with the Secretary of State, Securities Division. To become registered as an originator, an individual must submit an Application for Registration as a Principal Manager or as an Originator (State Form 49718/Form LB 4) with the Secretary of State, Securities Division. C. Section 10 of this form must be signed by an authorized party of the applicant. State Form 53264 (R2 / 4-08) / Form LB 3 Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com B. EXPLANATION OF TERMS – The following terms are the italicized terms used throughout State Form 53264/Form LB 3 and have the following meaning. APPLICANT – The loan broker applying on or amending information on this form for a branch office. The only instance in which the applicant is an individual is in the case of a sole proprietorship. 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. REST OF PAGE INTENTIONALLY LEFT BLANK State Form 53264 (R2 / 4-08) / Form LB 3 Page 2 of 4 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 BRANCH OFFICE NOTIFICATION State Form 53264 (R2 / 4-08) / Form LB 3 Applicant full legal name Date (MM/DD/YYYY): License Number Information (if applicable). Use additional sheets if necessary. License # Jurisdiction License # Jurisdiction License # Jurisdiction License # Jurisdiction 1. AMENDMENT To amend, circle or identify item(s) being amended 2a. INITIAL NOTIFICATION Physical Address (Number & Street) Physical City 2b. State/Country State/Country Zip + 4/Postal Code Mailing address or P.O. Box (if different from Physical) Mailing address City 3b. Zip + 4/Postal Code NEW Physical Address (Number & Street) NEW Physical City 3a. CEASING OPERATIONS State/Country Zip + 4/Postal Code NEW Mailing address or P.O. Box (if different from Physical) NEW Mailing address City State/Country Zip + 4/Postal Code 4a. Business (Area Code) & Telephone Number Fax (Area Code) & Number Branch website (enter “None” if not applicable) 4b. NEW Business (Area Code) & Telephone Number NEW Fax (Area Code) & Number NEW Branch website (enter “None” if not applicable) 5a. Trade name or “dba” used at this branch office 5b. NEW Trade name or “dba” used at this branch office 6a. Principal Manager Name: Last Name First Name Middle Name Registration Number NEW Principal Manager Name: Last Name First Name Middle Name Registration Number 6b. State Form 53264 (R2 / 4-08) / Form LB 3 Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com Applicant full legal name: ______________________________________________________ 7. 8. 9. Will this branch office and/or individuals at this branch office operate pursuant to a written agreement YES or contract with the applicant’s principal office? Will this branch office have sole responsibility for decisions relating to individuals originating or YES soliciting mortgage loans: (a) with respect to employment? (b) with respect to compensation? Does any person, other than the applicant, have responsibility, directly or indirectly, for paying the YES expenses of this branch office or otherwise have a financial interest in this branch office or its activities? (a) If yes, provide an explanation of the expense payment and/or financial interest arrangement: NO NO NO (b) If yes, provide the following information for each person responsible for the expenses or with a financial interest: Full Legal Name (Individuals: Last Name, First Name, Middle Name) Address, City, State/Province, Zip/Postal Code Telephone IRS Tax No., SSN, or Employer ID Number Separately Licensed? Yes No 10. VERIFICATION: I, ________________________________, do solemnly swear or affirm under the penalties of perjury that the information appearing in this form and the attached documents hereto is true, accurate, and complete to the best of my knowledge. Signature Title Date (MM/DD/YYYY) REST OF PAGE INTENTIONALLY LEFT BLANK State Form 53264 (R2 / 4-08) / Form LB 3 Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com