CLAIM OF EXEMPTION State Form 53265 (R3/4-08) / Form LB 5 Approved by State Board of Accounts, 2007 Explanation and Instructions A person claiming an exemption from the licensing and registration requirements of the Indiana Loan Broker Act pursuant to Indiana Code § 23-2-5-19(a)(8) must file this claim with the Indiana Secretary of State, Securities Division. Before completing this form, you should read and be familiar with the Indiana Loan Broker Act, codified in Indiana Code Chapter 23-2-5 and the rules relating to the Act which are contained in Indiana Administrative Code Chapter 710 IAC 1-22. You may access the statutes and rules through the Division’s website: www.sos.IN.gov/securities. This properly completed form must be accompanied by: • $200 non-refundable fee, payable to the “Indiana Secretary of State”; • Names of all employees conducting origination activities in Indiana; • List of the address(s) of all branch offices located, or engaging in origination activities in Indiana; and • Evidence supporting the claim of exemption. • DO NOT include the instructions (pages 1-3 of this form). 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 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 exempt loan broker’s name. Submit the 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 THE INDIANA SECRETARY OF STATE, SECURITIES DIVISION HAS NOT IN ANY WAY PASSED UPON THE ACCURACY OR ADEQUACY OF THIS CLAIM OF EXEMPTION FROM INDIANA CODE 23-2-5. ANY REPRESENTATION TO THE CONTRARY IS A CRIMINAL OFFENSE. A. GENERAL INSTRUCTIONS 1. TERMS USED – See the following Explanation of Terms section regarding italicized words/phrases used throughout this State Form 53265/Form LB 5. 2. AMENDMENTS – Pursuant to Indiana Code § 23-2-5-19(e) the exempt loan broker must notify the Indiana Secretary of State, Securities Division of a change in any information contained in this form by submitting amendments using State Form 53265/Form LB 5. Check the “Amendment” box, complete the Sections 2(A) and 5, and, circle (or otherwise identify) and complete the item(s) being amended. For name and/or address amendments, the exempt loan broker must submit the required evidence listed on page three (3) of this form reflecting the new full legal name and/or address. 3. TERMINATE / CANCEL– When an exempt loan broker decides to cease operations under the exemption, use the State Form 53265/Form LB 5 to notify the Indiana Secretary of State, Securities Division by checking the “Terminate/Cancel” box and completing only Sections 2(A) and 5. B. SECTION INSTRUCTIONS: Section 1 – TYPE OF EXEMPTION BEING CLAIMED: Check the box next to each type of exemption that is being claimed by the exempt loan broker. American LegalNet, Inc. www.FormsWorkflow.com State Form 53265 (R3 / 4-08) / Form LB 5 Page 1 of 7 B. SECTION INSTRUCTIONS (cont.) Section 2 - NAME AND CONTACT INFORMATION: Complete each line. The name on file will appear exactly as reported in 2(A). All correspondence will be sent to the address reported in 2(B). List the full legal names under which loan broker business will be conducted in the State of Indiana (NOTE: the evidence submitted supporting the claim of exemption must reflect all of the exempt loan broker’s full legal names under which loan broker business will be conducted). The individual listed as the contact employee must be authorized to receive all compliance and licensing information, communications, and mailings, and be responsible for disseminating it within the exempt loan broker’s organization. Section 3 – BUSINESS ENTITY INFORMATION: Check the appropriate box and complete the additional information requested. When you submit this form 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 and assumed names (if applicable) by contacting the Indiana Secretary of State, Business Services Division, at www.sos.IN.gov/business or (317) 232.6576. Section 4 – EVIDENCE SUPPORTING CLAIM OF EXEMPTION Check the box that applies. The evidence submitted supporting the claim of exemption must reflect the full legal name of the exempt loan broker, any “dba’s,” under which loan brokerage business is to be conduced, and the current address of the exempt loan broker. Section 5 – VERIFICATION By signing the verification, the exempt loan broker is affirming that the information appearing in this form is true and complete. Schedule A – ORIGINATORS List the full legal name, date of birth, business address, and business telephone number for each employee conducting origination activities in Indiana. To notify the Securities Division of new originators, check the “Addition” box. To notify the Securities Division of the termination of an originator, check the “Termination” box. The Exempt Loan Broker Must notify the Securities Division of the addition/termination of originators as they occur. Schedule B – BRANCH OFFICES List the address, telephone number, and name (if different from 2(A)) of each branch office located or engaging in origination activities in Indiana. Exempt loan broker must submit evidence that shows the claim of exemption extends to each branch office listed. C. EXPLANATION OF TERMS CONTACT EMPLOYEE – The individual authorized to receive all compliance and licensing information, communications, and mailings, and be responsible for disseminating it within the exempt loan broker’s organization. EXEMPT LOAN BROKER – Any person authorized to: (1) sell and service a loan for the Federal National Mortgage Association (“Fannie Mae”) or the Federal Home Loan Mortgage Association (“Freddie Mac”), (2) issue securities backed by the Government National Mortgage Association (“Ginnie Mae”), (3) make loans insured by the United States Department of Housing and Urban Development (“HUD”) or the United States Department of Agriculture Rural Housing Service (“USDA”), (4) act as a supervised lender or non-supervised automatic lender of the United States Department of Veterans Affairs (“VA”), (5) or act as a correspondent of loans insured by the United States Department of Housing and Urban Development (“HUD”), if the person closes at least twenty-five (25) such insured loans in Indiana during each calendar year. ORIGINATOR – A person engaged in origination activities. ORIGINATION ACTIVITIES - Means communication with or assistance of a borrower or prospective borrower in the selection of loan products or terms. PROOF OF EXEMPTION – see attached “Required Proof for Filing an Exemption” on page 3 of this notification form. 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. American LegalNet, Inc. www.FormsWorkflow.com State Form 53265 (R3 / 4-08) / Form LB 5 Page 2 of 7 Required Evidence for Claiming an Exemption If claiming a: Fannie Mae (Federal National Mortgage Association) exemption Freddie Mac (Federal Home Loan Mortgage Corporation) exemption Ginnie Mae (Government National Mortgage Association) exemption USDA (United States Department of Agriculture Rural Housing Service) exemption HUD Lender exemption (i.e. Supervised or Nonsupervised Mortgagee) HUD Loan Correspondent exemption (i.e. Supervised or Non-supervised Loan Correspondent) VA (United States Department of Veterans Affairs) exemption Note: Pursuant to Indiana Code § 23-2-5-19(f) an exemption that applies to a person under Indiana Code § 23-2-5-19(a)(8)(D) does not extend to a registered United States Department of Veterans Affairs agent. Then evidence must include: copy of letter from Fannie Mae stating the loan broker is “authorized to sell and service loans for the Federal National Mortgage Association” copy of letter from Freddie Mac stating the loan broker is “authorized to sell and service loans for the Federal Home Loan Mortgage Corporation” copy of letter from Ginnie Mae stating the loan broker is “authorized to issue securities backed by the Government National Mortgage Association” copy of letter from USDA stating the loan broker is “authorized to make loans insured by the United States Department of Agriculture Rural Housing Service (or USDA)” copy of letter from HUD stating the loan broker is “authorized to make loans insured by the United States Department of Housing and Urban Development (or HUD)” copy of letter from HUD stating the loan broker is “authorized to act as a correspondent of loans insured by the United States Department of Housing and Urban Development (or HUD)” -ANDa statement of the number of HUD insured loans that the loan broker has closed in the state of Indiana during the last calendar year and during the current year as of the last practicable date. Copy of letter from VA stating the loan broker is “authorized to act as a supervised lender of the United States Department of Veterans Affairs (or VA)” -orcopy of letter from VA stating the loan broker is “authorized to act as a nonsupervised automatic lender of the United States Department of Veterans Affairs (or VA)” REST OF PAGE INTENTIONALLY LEFT BLANK American LegalNet, Inc. www.FormsWorkflow.com State Form 53265 (R3 / 4-08) / Form LB 5 Page 3 of 7 Todd Rokita Indiana Secretary of State Securities Division 302. W. Washington Street, E-111 Indianapolis, Indiana 46204 (317) 232-6681 CLAIM OF EXEMPTION State Form 53265 (R3 / 4-08) / Form LB 5 Approved by State Board of Accounts, 2007 Date (MM/DD/YYYY) Initial Notification Terminate/Cancel Amendment To amend, circle or identify item(s) being amended Renewal Notification SECTION 1. TYPE OF EXEMPTION BEING CLAIMED (check all that apply): Fannie Mae HUD Lender Freddie Mac HUD Loan Correspondent Ginnie Mae VA USDA SECTION 2. NAME AND CONTACT INFORMATION: (A) Name of Exempt Loan Broker Business (B) List all names under which loan broker business will be conducted in Indiana (C) FOR AMENDMENTS ONLY (if the exempt loan broker’s name has changed, enter the previous name in Section 1(A) and the new name here) (D) Street Address of Principal Office (Do not use a P.O. Box) City State Zip+4/Postal Code (E) Mailing Address, if different from Principal Office address (May use P.O. Box) City State (F) Telephone Number (H) Contact Employee: Last Name Zip +4/Postal Code (G) Fax Number First Name Middle Name (I) E-mail Address for Contact Employee 3. BUSINESS ENTITY INFORMATION: (A) Indicate legal status of exempt loan broker. Corporation Sole Proprietorship Partnership (B) Exempt loan broker’s fiscal year end (MM/DD): Limited Liability Company Other (specify) _________________ (C) If other than a sole proprietorship, indicate date and place exempt loan broker was formed: State/Province & Country of formation Date of Formation (MM/DD/YYYY) American LegalNet, Inc. www.FormsWorkflow.com State Form 53265 (R3 / 4-08) / Form LB 5 Page 4 of 7 SECTION 4. EVIDENCE SUPPORTING CLAIM OF EXEMPTION Is the evidence supporting claim of exemption attached? YES NO SECTION 5. VERIFICATION: I, __________________________________, do solemnly swear or affirm under the penalties of perjury that: A. each employee conducting origination activities in the State of Indiana on behalf of the exempt loan broker is listed on Schedule A of this form; and B. the information appearing in this form and the attached documents hereto is true, accurate, and complete to the best of my knowledge. Signature Title CHECK HERE Date (MM/DD/YYYY) CLAIM OF EXEMPTION CHECKLIST THE FOLLOWING INFORMATION MUST BE COMPLETED OR ATTACHED TO THIS FORM $200.00 fee Section 1 – Type of Exemption Being Claimed: Checked what type of exemption(s) the exempt loan broker is claiming. Section 2 – Name and Contact Information: Provided the following: • Full legal name(s) of the exempt loan broker (Section 2(A)) • Principal Office Address (Section 2(D)) • Telephone Number (Section 2(f)) • Contact Employee (Section 2(H)) Section 3 – Business Entity Information: • Exempt loan broker and any assumed name(s) are properly registered with the Indiana Secretary of State, Business Services Division; and • Provided the following information: • Exempt loan broker’s legal status; • Exempt loan broker’s fiscal year end; and • Formation information Section 4 – Evidence Supporting Claim of Exemption: Exempt loan broker has provided the required evidence supporting the claim of exemption. Section 5 – Verification: Signed and dated Schedule A – Originators: Provided the required information for each employee that is engaging in origination activities in the State of Indiana. Schedule B – Branch Office Locations: Provided the following: • The required information for each office location that is either located or engaging in origination activities, in the State of Indiana. • Evidence showing that the exemption claimed extends to each of the branch office locations identified. REST OF PAGE INTENTIONALLY LEFT BLANK American LegalNet, Inc. www.FormsWorkflow.com State Form 53265 (R3 / 4-08) / Form LB 5 Page 5 of 7 SCHEDULE A ORIGINATORS Exempt Loan Broker’s Full Legal Name ADDITION (A) Full Name of Originator Last Name TERMINATION First Name Middle Name Date of Birth (MM/DD/YYYY) Business Address of Originator City State Zip+4/Postal Code ADDITION (B) Full Name of Originator Last Name Business Telephone Number TERMINATION First Name Middle Name Date of Birth (MM/DD/YYYY) Business Address of Originator City State Zip+4/Postal Code ADDITION (C) Full Name of Originator Last Name Business Telephone Number TERMINATION First Name Middle Name Date of Birth (MM/DD/YYYY) Business Address of Originator City State Zip+4/Postal Code ADDITION (D) Full Name of Originator Last Name Business Telephone Number TERMINATION First Name Middle Name Date of Birth (MM/DD/YYYY) Business Address of Originator City State Zip+4/Postal Code Business Telephone Number USE ADDITIONAL FORMS AS NEEDED American LegalNet, Inc. www.FormsWorkflow.com State Form 53265 (R3 / 4-08) / Form LB 5 Page 6 of 7 SCHEDULE B BRANCH OFFICE LOCATIONS Exempt Loan Broker’s Full Legal Name (A) Name(s) Address of Branch Office City State Zip+4/Postal Code State Zip+4/Postal Code State Zip+4/Postal Code State Zip+4/Postal Code State Zip+4/Postal Code Telephone Number (B) Name(s) Address of Branch Office City Telephone Number (C) Name(s) Address of Branch Office City Telephone Number (D) Name(s) Address of Branch Office City Telephone Number (E) Name(s) Address of Branch Office City Telephone Number USE ADDITIONAL FORMS AS NEEDED State Form 53265 (R3 / 4-08) / Form LB 5 American LegalNet, Inc. www.FormsWorkflow.com Page 7 of 7