CALCULATION OF LOAN BROKER APPLICATION FEE State Form 53304 (R / 6-08) Approved by State Board of Accounts, 2008 Applicant’s Full Legal Name ________________________________________________ Todd Rokita Indiana Secretary of State Securities Division 302. W. Washington Street, E-111 Indianapolis, Indiana 46204 (317) 232-6681 Date (MM/DD/YYYY) _________________ 1. This Form is used to determine the amount of the initial/renewal fee to be submitted with application for License as a Loan Broker (State Form 38168/Form LB 1), or Application for Registration as a Principal Manager or Originator (State Form 49718/Form LB 4). 2. Complete Each Column: In the first column, enter the full legal name of the person for whom the fee is being submitted. In the second column enter the category; and in the third column, enter the total fee amount for that row. 3. The following fees are required to be submitted with the application(s): - For License as a Loan Broker x An application fee of $400.00, $200.00 for each ultimate equitable owner, plus $32.25 for an FBI background check for each Ultimate Equitable Owner, director, manager and/or officer. - For Registration as a Principal Manager x An application fee of $200.00 plus $32.25 for an FBI background check. - For Registration as an Originator: x An application fee of $100.00 plus $32.25 for an FBI background check. Name of Individual or Entity (list the full legal name; for individuals: Last Name, First Name, Middle Name) Category (loan broker, ultimate equitable owner, principal manager, or originator) Total Fee to Be Submitted with Application Complete Additional Forms As Needed Amount Paid 0.00 American LegalNet, Inc. www.FormsWorkflow.com