CSCL/CCC-101 (02/15) Michigan Department of Licensing and Regulatory Affairs Corporations, Securities & Commercial Licensing Bureau Audit & Examination Division P.O. Box 30018, Lansing, MI 48909 517-335-2395 www.michigan.gov/securities CONSENT TO SERVICE OF PROCESS AUTHORITY: 2014 PA 448 PENALTY: FAILURE TO PROVIDE THIS INFORMATION MAY RESULT IN DENIAL OF THE APPLICATION AND/OR DISCIPLINARY ACTION. Information provided on this form may be released to the public in accordance with the Freedom of Information Act, 1976, PA 442, as amended. Name of Applicant Street Address City State ZIP Code Type of Application (check one) Individual Organization (corporation, limited liability company, partnership, etc.) If applicant is an organization, name the state in which you are organized. KNOW ALL PERSONS BY THESE PRESENTS: For the purpose of complying with the laws of the State of Michigan, the undersigned irrevocably appoints the Director of the Licensing Division, Corporations, Securities & Commercial Licensing Bureau in the Michigan Department of Licensing and Regulatory Affairs or his/her/its successor in office, to be his/her/its attorney to receive service of any lawful process in any non-criminal suit, action, or proceeding against him/her/it, or his/her/its successor, executor, or administrator, which may arise under the Continuing Care Community Disclosure Act (2014 PA 488) or any rule or order thereunder after the filing hereof. The undersigned does hereby consent that any such action, or proceeding against him/her/it may be commenced in any court of competent jurisdiction and proper venue within the State of Michigan by service of process upon said Director with the same force and validity as if served upon the undersigned by service personally on its president or other chief officer, if a corporation, or one its partners, if a partnership, or on one of its members, if a limited liability company, or on the individual, if an individual. Signed in the City of , State of this day of , 20 . Signed Name of Applicant By If an Organization Title State of County of Subscribed and sworn before me on this day of , 20 Signature of Notary Public My commission expires County of State of LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. American LegalNet, Inc. www.FormsWorkFlow.com