Please visit our website at www.com.ohio.gov/real 614|466 - 4100 Fax: 614|644 - 0584 TTY/TDD: 800|750 - 0750 Anne M. Petit , Superintendent MULTIPLE LICENSE TRANSFER/REACTIVATION AFFIDAVIT Th i s a ff i d a v i t s h a l l be us e d w h en t h e li c e n se o f m o re t h a n o n e b ro k er, sa le sper so n, o r br a n ch o ff i ce i s b ei ng t ran s fe r r e d or whe n t h e license of m o re than one broker, sale sp er so n, or br a n ch office is be i n g r e acti v ated from a Principal Brok e r su s p ens i on. ATTENTION : Effect i v e 7/01/2010, the s i gnatures of all licensees affe c t e d b y a t r a n sf e r must be o bt a i ned a n d submitted with this form. Ret u rn all fi v e p a g es o f t h e affi d a v it to t h e Di v i sio n . TRANSF E R Please complete and submit all five pages of the affidavit. Mark N/A on a n y pages that do not a p p l y . Tran s fer Fee S truc t ure : $25 for each brok e r, $25 for each sal e spe r son, and $ 1 5 for each b ran c h office, not to exceed $6,000 . R et urn t he c o m p a n y li c ense and a dde n d u m. I, , make the following affirmations based upon personal knowledge: (Print Principal Broker Name) 1. That each licensee whose name and license number is listed in Attachment A or Attachment B has been informed that his/her license will be transferred from to (Current Brokerage) (New Brokerage) on or about and has consented as indicated b y his/her signatu r e . (Date of Transfer) 2. Or, if he/she does not con s ent to said transfer, that his/her name and license nu m b er is listed in Attachment C. 3. That any affected branch office is listed in Attachment D. 4. That holds the Division harmless for any error or omission occurring in (New Brokerage) connection with the transfer of the licenses listed in Attac h m ent A o r Attac h ment B. Principal Broker Signature X Broker File# PLEASE NOTE: COMPLETE THE FOLLOWING TOTAL LICENSES TOTAL FEES ALL LICENSEES A F FECTED MUST SIGN PAGE 2 OR 3 OF THIS AFFIDAVIT. BROKERS (Attachment A) @ $25.00 $ SALESPEOPLE(Attachment B) @ $25.00 $ BRANCH OFFICES (Attachment D) @ $15.00 $ TOTAL FEE FOR ALL TRANSACTIONS $ REACTIVAT I ON - P lease c o mplete and sub m it all five pages of the affidavit. Mark N/A on a n y p age that does n o t app l y . Penal t y and reactivation fees app l y on l y t o the principal broker. T here is no charge to re ac tivate salespe o p l e, branch offices, or companies from a Sole - B r oker suspension. Retu r n all a f fe ct ed lice n ses including the comp an y or sole - broker license, all salesperson licenses, and a n y branch office licens e s . I, , m ake the following affi r mations based u p on pers o n al knowled g e: (Print Principal Broker Name) 1. That each li c ensee whose n a m e and lic en se nu m ber is listed in Attachment A or Attachment B has been informed that his/her l i cense will be reactivated to and has consented to such reactivation as indicated by his/her signature. (New Brokerage) 2. Or, if he/she does not consent to said reactivation, that the name and license number of those licensees who have not consented to such reactivation are listed in Attachment C. 3. That any affected branch office is listed in Attachment D. 4. That holds the Division harmless for any error or omission occurring in (New Brokerage) connection with the re a ctiv a tion of the li c enses listed in Attach m ent A or Attach m ent B. Reactivation Date: Principal Broker Signature: Broker File #: NOT I CE : This a pplication and the information co n tained therein, e xcept for social s e curi t y numb e rs, is public record pursuant to Oh i o Revised Code 149.43. REPL - 17 - 0015 COM 3683 Equal Opportunity Employer and Service Provide r Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com ATTENTION TRANSFERRING OR REACTIVATING BROKERS: BY SIGNING THIS PAGE, YOU ARE CONSENTING TO THE TRANSFER DESCRIBED ON PAGE ONE OF THIS AFFIDAVIT. ATTACHMENT A - BROKERS FEE: $25 PER BROKER OLD BROKERA G E NAME OLD FILE NUMB E R N E W BROKERA G E NAME ( F OR TRANSFERS ONL Y ) N E W FILE N U MB E R (FOR TRANSFERS ONLY) N E W BROKERA G E ADDRESS (FOR TRANSFERS ON LY ) N E W PHONE NE W FAX C I TY COUN T Y STAT E ZIP CODE FILE N U MBER P RINT F U L L N A M E O F B R O K ER SIG N A T URE TRANSF E R TH E SE TOT A LS TO THE TABLE ON PAGE 1 Attach additional pages as needed TOTAL NUMB E R OF BROKERS L I CENS E S TOTAL BROKER TRAN S FER FEES $ Page 2 of 5 REPL - 17 - 0015 COM 3683 American LegalNet, Inc. www.FormsWorkFlow.com ATTENTION TRANSFERRING OR REACTIVATING SALESPERSONS: BY SIGNING THIS PAGE, YOU ARE CONSENTING TO THE TRANSFER DESCRIBED ON PAGE ONE OF THIS AFFIDAVIT. ATTACHMENT B - SALESPERSON FEE: $25 PER S A LESPER S ON OLD BROKERA G E NAME OLD FILE NUMB E R N E W BROKERA G E NAME (FOR TRA N SFERS ONL Y ) N E W F I LE NUMBER (FOR TR A N SF E R S ONLY) N E W BROKERA G E ADDRESS (FOR TRANSFERS ON LY ) N E W PHONE NE W FAX C I TY COUN T Y STATE ZIP CODE FILE N U MBER PRINT FULL N A ME O F S A LES P ERS O N S A SI G N A T URE TRANSF E R TH E SE TOT A LS TO THE TABLE ON PAGE 1. Attach additional pages as needed. TOTAL NUMB E R OF SALESPERSON L I CENS E S TOTAL SALES P ERSON TRAN S FER FEES $ REPL - 17 - 0015 COM 3683 Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com THE LICENSEES LISTED BELOW DO NOT CONSENT TO TRANSFER. ATTACHMENT C NOT CONSENTED OLD BROKERA G E NAME OL D F I L E NUMBER N E W BROKERA G E NAME (FOR T R ANSFERS ONL Y ) N E W F I LE NU M BER (FOR TRA N SFERS ONL Y ) N E W BROKERA G E ADDRESS (FOR TRANSFERS ON LY ) N E W PHONE NE W FAX C I TY COUN T Y STATE ZIP CODE FULL N A M E O F LICENSEE LICENSE TYPE LICENSE N U M B ER BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON BROKER SAL E SPER S ON Attach additional pages as needed. REPL - 17 - 0015 COM 3683 Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com ATTACHMENT D BRANCH OFF I CES FEE: $15 PER B R AN C H OLD BROKERAGE NAME OLD FILE NUMBER NEW BROKERAGE NAME (FOR TRANSFERS ONLY) NEW FILE NUMBER (FOR TRANSFERS ONLY) NEW BROKERAGE ADDRESS(FOR TRANSFERS ONLY) NEW PHONE NEW FAX CITY STATE ZIP CODE BRANCH OFFICE INFORMATION OLD BRANCH OFFICE ADDRESS OLD FILE NUMBER CITY STATE ZIP CODE NEW BRANCH OFFICE ADDRESS NEW FILE NUMBER CITY STATE ZIP CODE BRANCH OFFICE INFORMATION OLD BRANCH OFFICE ADDRESS OLD FILE NUMBER CITY STATE ZIP CODE NEW BRANCH OFFICE ADDRESS NEW FILE NUMBER CITY STATE ZIP CODE BRANCH OFFICE INFORMATION OLD BRANCH OFFICE ADDRESS OLD FILE NUMBER CITY STATE ZIP CODE NEW BRANCH OFFICE ADDRESS NEW FILE NUMBER CITY STATE ZIP CODE BRANCH OFFICE INFORMATION OLD BRANCH OFFICE ADDRESS OLD FILE NUMBER CITY STATE ZIP CODE NEW BRANCH OFFICE ADDRESS NEW FILE NUMBER CITY STATE ZIP CODE BRANCH OFFICE INFORMATION OLD BRANCH OFFICE ADDRESS OLD FILE NUMBER CITY STATE ZIP CODE NEW BRANCH OFFICE ADDRESS NEW FILE NUMBER CITY STATE ZIP CODE TRANSFER THESE TOTALS TO THE TABLE ON PAGE 1 Attach additional pages as needed TOTAL NUMBER OF BRANCH LICENSES TOTAL BRANCH OFFICE TRANSFER FEES $ Page 5 of 5 REPL-17-0015 COM 3683 American LegalNet, Inc. www.FormsWorkFlow.com