FIS 0503 (04/11) Office of Financial and Insurance Regulation Sales Agent Statement of Compliance Instructions: Sales agents must complete this form in conjunction with the initial or renewal registration of the living care facility. Pursuant to Section 27 of the Living Care Disclosure Act (the "Act"), the Office of Financial and Insurance Regulation ("OFIR") of the State of Michigan promulgated Living Care Rule 5, which states: 1. Pursuant to the provisions of Section 27 of the Act, life interest and long-term lease sales agents may participate in the offer or sale of a life interest or long-term lease if the sales agent meets all of the following criteria: a. Does not engage in the offer or sale of life interests or long-term leases for more than 1 principal. b. Does not execute sales contracts or life interest or long-term leases or collect funds pertaining thereto unless the sales agent has written authorization from the facility. c. Has not previously employed, in connection with the purchase or sale of a life interest or longterm lease, a device, scheme, or artifice to defraud. d. Has not violated, or failed to comply with, the Act, these rules, or an order of OFIR. e. Has not engaged in unfair, unconscionable, or deceptive business practices. Examples are recommending the purchase of life interests or long-term leases without reasonable grounds to believe that the recommendations are suitable for the individual on the basis of information furnished by the individual after such reasonable inquiry as may be necessary under the circumstances. f. Has not been convicted of a misdemeanor involving deceit and has not been convicted of any felony. g. Has not been the subject of an administrative order of a state or federal agency relating to, or been permanently or temporarily enjoined by a court of competent jurisdiction from engaging in or continuing, any conduct or practice involving any aspect of the securities, franchise, real estate, banking, or insurance business. h. Has not been the subject of an order of a state, federal, or self-regulatory agency denying, suspending, or revoking registration as a broker-dealer, agent, investment adviser, or franchise agent or any other similar registration. 2. OFIR may, by order, waive any of the criteria specified in subrule (1) of this rule and allow a person to participate in the offer or sale of a life interest or long-term lease as an agent. In compliance with the Act,___________________________, sales agent at _____________________________, certifies that he(she) meets the criteria listed above and that he(she) complies with the rules for life interest or long-term lease sales agents promulgated by OFIR. _________________________________ Signature This form is issued under Section 25 of Act 440, PA of 1976, as amended, and Rule 5 Failure to complete or submit this form, false statements, or omissions may result in Rejection of your application, denial or revocation of registration, and other civil and criminal action. ____________________________ Date Office of Financial and Insurance Regulation/Securities P.O. Box 30701 Lansing, MI 48909-8201 Our Delivery Address: 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