FIS 0502 (04/11) Office of Financial and Insurance Regulation Living Care Disclosure Act Occupancy/Sales and Proceeds Report Directions: Facilities must complete all sections of this form within 30 days of the end of their fiscal quarter. Registration No. LCI. Facility Information Facility Name d/b/a Address City State Zip II. Sales and Proceeds Quarter Ending Number of Life Interests or Long Term Leases Sold During the Quarter Total Amount of Proceeds Derived From Sales During the Quarter / / III. Occupancy $ Report Period (Check only one, enter month, day year) · First Quarter Ended · Second Quarter Ended / / / / % Third Quarter Ended ___/____/___ 9 Fourth Quarter Ended ___/____/___ Total Number of Units ______________ Percentage of Occupancy of the Facility Number of Occupants Who Have Life Interests or Long-Term Leases ______________________ IV. Signature _____________________________________________________________________________________________________________________________________________________________ Signature of authorized agent of Facility _____________________________________________________________________________________________________________________________________________________________ Print Name This form is issued under Act 440, PA of 1976, as amended, and Rule 21. When complete, please return to: Office of Financial and Insurance Regulation/Securities P.O. Box 30701 Lansing, MI 48909-8201 Our Delivery Address: This form is available in PDF format from our Web site at: http://www.michigan.gov/ofir Office of Financial and Insurance Regulation/Securities st 525 West Allegan Street, 1 Floor North Lansing, MI 48933-1502 American LegalNet, Inc. www.FormsWorkFlow.com