FIS 0501 (04/11) Office of Financial and Insurance Regulation Living Care Disclosure Act Registration Application Type of Filing __ REGISTRATION __ RENEWAL __ AMENDMENT Fee.....$250 Fee.....$100 No Fee Registration No. LC- If amendment, provide nature of change (1) __Disclosure Statement (marked copy enclosed) __ Change in fees __ Financial Statements __ Other (2) __Application Form __Change in sales agents (list enclosed) __Change in officers, directors, etc. (see Exhibit 8) (list enclosed) (3) __Other documents ____________________ Facility Information Facility Name d/b/a Address City State Zip Organization Form __Corporation __Limited Partnership __Limited Liability Company __Association __Other ________________ __Profit __Non-Profit IRS Status __501(c)(3) __501(c)(4) Date and Place of Organization Date Place Name of Certified Public Accounting Firm Auditing Facility=s Financial Statements Name of Firm Address City State Zip Code Telephone Has there been a change in accounting firms since the facility filed its last financial statement? Sales Agent Information Yes No __ Attached is a list of life interest or long-term lease agents which the facility has determined meet the criteria of Rule 5(1). Person to Whom Communications Regarding this Application Should be Directed Name Firm or Company Address City State Zip Code Telephone American LegalNet, Inc. www.FormsWorkFlow.com FIS 0501 (04/11) Office of Financial and Insurance Regulation Signature The undersigned, being first duly sworn, deposes and says that the undersigned has executed the foregoing application for and on behalf of the applicant named therein, that the undersigned is the of such applicant and is fully authorized to execute and file such application; that the undersigned is familiar with such application including the exhibits thereto; and that to the best of the undersigned=s knowledge, information and belief the statements made in such application including the exhibits thereto are true and the copies of the documents submitted therewith are true copies of the originals thereof. Dated this day of Month For: Name of facility , _________ Year By: ________________________________________ Signature of Authorized Agent of Facility _________________________________________________________________ Print Name _____________________________________ Title of Agent for Facility STATE OF ___________________________________ COUNTY OF _________________________________ Subscribed and sworn to before this day of ________________________. , Notary Public County of State of _______________________ My Commission Expires _____________________________________ Waiver of Automatic Effectiveness hereby waives the automatic effectiveness provision of (Name of Applicant) Section 8(7) of the Living Care Disclosure Act, as amended, and agrees not to sell or offer to sell a life interest or longterm lease in the State of Michigan until the registration of _______________________________________________ (Name of Facility) has been rendered effective by the Office of Financial and Insurance Regulation. Name of Applicant Dated By Title This form is issued under Act 440, PA of 1976, as amended. You must complete and submit this form to make an application for registration under Section 8 of the Act. 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 FIS 0501 (04/11) Office of Financial and Insurance Regulation Instructions for Completing Living Care Disclosure Act Registration Form Type of Filing - Check Registration if facility is filing for initial registration. Check Renewal if registration renewal. (Section 21 provides renewal application must be submitted not later than 30 business days before the expiration of the registration.). Check Amendment to submit for approval a material change in the information contained in the application pursuant to Section 22 and Rule (1)(2). Amendment - Check appropriate box. Facilities are required to submit notification of change of fees to the Office of Financial and Insurance Regulation through amendment to disclosure statement pursuant to Rule 24. Section 8(1)(f) requires that financial information in the Disclosure Statement be updated at least annually. Registration No. - Enter file number if assigned. Name of Facility - Enter name of facility. d/b/a - Enter name under which the applicant is doing or intends to do business. Address - Enter physical location of facility. Organization Form - Check applicable box. If "other", provide which type. If Organization is Corporation - Check whether profit or non-profit. Section 5(5) A...a nonprofit corporation shall comply with the requirements of Section 501(c)(3) or Section 501(c)(4) of the Internal Revenue Code.@ Date and Place of Organization - Enter date of organization and the state. Name of Certified Public Accounting Firm - Enter the name and address of the accounting firm that is currently engaged by the facility and prepared the facility=s most recently filed certified financial statements. Has there been a change in accounting firms? - Check the applicable box. When "Yes@ is checked, also submit required documents pursuant to Rule 68. See Additional Information for excerpt of Rule 68. Person to whom communications regarding this application should be directed - Enter applicable information for correspondence and notification. Sales Agent Information - Attach a list of life interest or long-term lease agents that the facility has determined meet the criteria of Rule 5(1). See Additional Information for excerpt of Rule 5(1). Signature - This area is to be completed, signed and notarized. Section 8(3) states, "An application for registration shall be signed and verified by the chief operating officer of the facility.@ Waiver of Automatic Effectiveness - Please complete this section to waive the provisions of Section 8(7) which states, "Within 30 days after the date of the notice of filing, the Office of Financial and Insurance Regulation shall enter an order registering the facility or rejecting the registration with notice of specific deficiencies therein. If an order of rejection is not entered withi