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Claim of Exemption Form Alabama

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					                                                 CLAIM OF EXEMPTION
                                             State Form 53265 (R3/4-08) / Form LB 5
                                            Approved by State Board of Accounts, 2007

                                               Explanation and Instructions

A person claiming an exemption from the licensing and registration requirements of the Indiana Loan Broker Act pursuant to
Indiana Code § 23-2-5-19(a)(8) must file this claim with the Indiana Secretary of State, Securities Division. Before completing
this form, you should read and be familiar with the Indiana Loan Broker Act, codified in Indiana Code Chapter 23-2-5 and the
rules relating to the Act which are contained in Indiana Administrative Code Chapter 710 IAC 1-22. You may access the
statutes and rules through the Division’s website: www.sos.IN.gov/securities.

This properly completed form must be accompanied by:
    • $200 non-refundable fee, payable to the “Indiana Secretary of State”;
    • Names of all employees conducting origination activities in Indiana;
    • List of the address(s) of all branch offices located, or engaging in origination activities in Indiana; and
    • Evidence supporting the claim of exemption.
    • DO NOT include the instructions (pages 1-3 of this form).

A PERSON WHO KNOWINGLY FILES WITH THE COMMISSIONER ANY DOCUMENT OR STATEMENT THAT
CONTAINS A FALSE REPRESENTATION OF A MATERIAL FACT IS SUBJECT TO THE IMPOSITION OF A CIVIL
PENALTY OF UP TO $10,000 PER VIOLATION; AND CHARGED WITH A CLASS C FELONY WHICH IS
PUNISHABLE BY A FINE UP TO $10,000 PER VIOLATION AND UP TO EIGHT (8) YEARS OF IMPRISONMENT.

If the space provided for any answer is inadequate, complete your answer on a separate sheet, specifying the question to which
it relates and attach this sheet to the application. For each additional sheet you provide, sign and list the exempt loan broker’s
name.

Submit the properly completed form along with any supporting documentation to the following address:

                                                  Indiana Secretary of State
                                                     Securities Division
                                             302 W. Washington St., Room E – 111
                                                 Indianapolis, Indiana 46204

THE INDIANA SECRETARY OF STATE, SECURITIES DIVISION HAS NOT IN ANY WAY PASSED UPON THE
ACCURACY OR ADEQUACY OF THIS CLAIM OF EXEMPTION FROM INDIANA CODE 23-2-5. ANY
REPRESENTATION TO THE CONTRARY IS A CRIMINAL OFFENSE.

A. GENERAL INSTRUCTIONS
    1. TERMS USED – See the following Explanation of Terms section regarding italicized words/phrases used throughout
       this State Form 53265/Form LB 5.
    2. AMENDMENTS – Pursuant to Indiana Code § 23-2-5-19(e) the exempt loan broker must notify the Indiana Secretary
       of State, Securities Division of a change in any information contained in this form by submitting amendments using
       State Form 53265/Form LB 5. Check the “Amendment” box, complete the Sections 2(A) and 5, and, circle (or
       otherwise identify) and complete the item(s) being amended. For name and/or address amendments, the exempt loan
       broker must submit the required evidence listed on page three (3) of this form reflecting the new full legal name and/or
       address.
    3. TERMINATE / CANCEL– When an exempt loan broker decides to cease operations under the exemption, use the
       State Form 53265/Form LB 5 to notify the Indiana Secretary of State, Securities Division by checking the
       “Terminate/Cancel” box and completing only Sections 2(A) and 5.
B. SECTION INSTRUCTIONS:
Section 1 – TYPE OF EXEMPTION BEING CLAIMED:
Check the box next to each type of exemption that is being claimed by the exempt loan broker.




State Form 53265 (R3 / 4-08) / Form LB 5                                                                            Page 1 of 7
B. SECTION INSTRUCTIONS (cont.)

Section 2 - NAME AND CONTACT INFORMATION:
Complete each line. The name on file will appear exactly as reported in 2(A). All correspondence will be sent to the address
reported in 2(B). List the full legal names under which loan broker business will be conducted in the State of Indiana (NOTE:
the evidence submitted supporting the claim of exemption must reflect all of the exempt loan broker’s full legal names under
which loan broker business will be conducted). The individual listed as the contact employee must be authorized to receive all
compliance and licensing information, communications, and mailings, and be responsible for disseminating it within the exempt
loan broker’s organization.

Section 3 – BUSINESS ENTITY INFORMATION:
Check the appropriate box and complete the additional information requested.
When you submit this form you are affirming that:
    A. All information is true and complete;
    B. A business entity required to file reports with the Business Services Division of the Secretary of State’s office is current
        in the filing of the reports; and
    C. A business entity formed in a state other than Indiana has properly qualified to do business in Indiana.
You may want to confirm the status of your business entity and assumed names (if applicable) by contacting the Indiana
Secretary of State, Business Services Division, at www.sos.IN.gov/business or (317) 232.6576.

Section 4 – EVIDENCE SUPPORTING CLAIM OF EXEMPTION
Check the box that applies. The evidence submitted supporting the claim of exemption must reflect the full legal name of the
exempt loan broker, any “dba’s,” under which loan brokerage business is to be conduced, and the current address of the exempt
loan broker.

Section 5 – VERIFICATION
By signing the verification, the exempt loan broker is affirming that the information appearing in this form is true and complete.

Schedule A – ORIGINATORS
List the full legal name, date of birth, business address, and business telephone number for each employee conducting
origination activities in Indiana. To notify the Securities Division of new originators, check the “Addition” box. To notify the
Securities Division of the termination of an originator, check the “Termination” box. The Exempt Loan Broker Must notify the
Securities Division of the addition/termination of originators as they occur.

Schedule B – BRANCH OFFICES
List the address, telephone number, and name (if different from 2(A)) of each branch office located or engaging in origination
activities in Indiana. Exempt loan broker must submit evidence that shows the claim of exemption extends to each branch
office listed.

C. EXPLANATION OF TERMS
      CONTACT EMPLOYEE – The individual authorized to receive all compliance and licensing information,
      communications, and mailings, and be responsible for disseminating it within the exempt loan broker’s organization.
      EXEMPT LOAN BROKER – Any person authorized to: (1) sell and service a loan for the Federal National Mortgage
      Association (“Fannie Mae”) or the Federal Home Loan Mortgage Association (“Freddie Mac”), (2) issue securities
      backed by the Government National Mortgage Association (“Ginnie Mae”), (3) make loans insured by the United
      States Department of Housing and Urban Development (“HUD”) or the United States Department of Agriculture Rural
      Housing Service (“USDA”), (4) act as a supervised lender or non-supervised automatic lender of the United States
      Department of Veterans Affairs (“VA”), (5) or act as a correspondent of loans insured by the United States Department
      of Housing and Urban Development (“HUD”), if the person closes at least twenty-five (25) such insured loans in
      Indiana during each calendar year.
      ORIGINATOR – A person engaged in origination activities.
      ORIGINATION ACTIVITIES - Means communication with or assistance of a borrower or prospective borrower in
      the selection of loan products or terms.
      PROOF OF EXEMPTION – see attached “Required Proof for Filing an Exemption” on page 3 of this notification
      form.
      PERSON – An individual, a partnership, a trust, a corporation, a limited liability company, a limited liability
      partnership, a sole proprietorship, a joint venture, a joint stock company, or another group or entity, however organized.




State Form 53265 (R3 / 4-08) / Form LB 5                                                                         Page 2 of 7
                         Required Evidence for Claiming an Exemption

     If claiming a:                                     Then evidence must include:
     Fannie Mae (Federal National Mortgage              copy of letter from Fannie Mae stating the loan
     Association) exemption                             broker is “authorized to sell and service loans for
                                                        the Federal National Mortgage Association”
     Freddie Mac (Federal Home Loan Mortgage            copy of letter from Freddie Mac stating the loan
     Corporation) exemption                             broker is “authorized to sell and service loans for
                                                        the Federal Home Loan Mortgage Corporation”
     Ginnie Mae (Government National Mortgage           copy of letter from Ginnie Mae stating the loan
     Association) exemption                             broker is “authorized to issue securities backed by
                                                        the Government National Mortgage Association”
     USDA (United States Department of Agriculture      copy of letter from USDA stating the loan broker
     Rural Housing Service) exemption                   is “authorized to make loans insured by the United
                                                        States Department of Agriculture Rural Housing
                                                        Service (or USDA)”
     HUD Lender exemption (i.e. Supervised or Non-      copy of letter from HUD stating the loan broker is
     supervised Mortgagee)                              “authorized to make loans insured by the United
                                                        States Department of Housing and Urban
                                                        Development (or HUD)”
     HUD Loan Correspondent exemption (i.e.             copy of letter from HUD stating the loan broker is
     Supervised or Non-supervised Loan                  “authorized to act as a correspondent of loans
     Correspondent)                                     insured by the United States Department of
                                                        Housing and Urban Development (or HUD)”
                                                        -AND-
                                                        a statement of the number of HUD insured loans
                                                        that the loan broker has closed in the state of
                                                        Indiana during the last calendar year and during
                                                        the current year as of the last practicable date.
     VA (United States Department of Veterans           Copy of letter from VA stating the loan broker is
     Affairs) exemption                                 “authorized to act as a supervised lender of the
                                                        United States Department of Veterans Affairs (or
                                                        VA)”
     Note: Pursuant to Indiana Code § 23-2-5-19(f) an   -or-
     exemption that applies to a person under Indiana   copy of letter from VA stating the loan broker is
     Code § 23-2-5-19(a)(8)(D) does not extend to a     “authorized to act as a nonsupervised automatic
     registered United States Department of Veterans    lender of the United States Department of
     Affairs agent.                                     Veterans Affairs (or VA)”




                            REST OF PAGE INTENTIONALLY LEFT BLANK




State Form 53265 (R3 / 4-08) / Form LB 5                                                        Page 3 of 7
                                                                                                             Todd Rokita
                                                                   Reset Form                         Indiana Secretary of State
           CLAIM OF EXEMPTION                                                                            Securities Division
           State Form 53265 (R3 / 4-08) / Form LB 5                                               302. W. Washington Street, E-111
           Approved by State Board of Accounts, 2007                                                 Indianapolis, Indiana 46204
                                                                                                           (317) 232-6681


Date (MM/DD/YYYY)
    Initial Notification                                       Amendment To amend, circle or identify item(s) being amended
    Terminate/Cancel                                           Renewal Notification

SECTION 1. TYPE OF EXEMPTION BEING CLAIMED (check all that apply):
   Fannie Mae                          Freddie Mac                      Ginnie Mae                     USDA
   HUD Lender                          HUD Loan Correspondent           VA

SECTION 2. NAME AND CONTACT INFORMATION:
(A) Name of Exempt Loan Broker Business


(B) List all names under which loan broker business will be conducted in Indiana


(C) FOR AMENDMENTS ONLY (if the exempt loan broker’s name has changed, enter the previous name in Section 1(A) and the
new name here)

(D) Street Address of Principal Office (Do not use a P.O. Box)


 City                                          State                                    Zip+4/Postal Code


(E) Mailing Address, if different from Principal Office address (May use P.O. Box)


 City                                          State                                    Zip +4/Postal Code


(F) Telephone Number                                                (G) Fax Number


(H) Contact Employee:
 Last Name                                     First Name                               Middle Name


(I) E-mail Address for Contact Employee



3. BUSINESS ENTITY INFORMATION:
(A) Indicate legal status of exempt loan broker.
        Corporation       Sole Proprietorship    Partnership     Limited Liability Company   Other (specify) _________________
(B) Exempt loan broker’s fiscal year end (MM/DD):

(C) If other than a sole proprietorship, indicate date and place exempt loan broker was formed:
 State/Province & Country of formation                                Date of Formation (MM/DD/YYYY)




State Form 53265 (R3 / 4-08) / Form LB 5                                                                          Page 4 of 7
SECTION 4. EVIDENCE SUPPORTING CLAIM OF EXEMPTION
Is the evidence supporting claim of exemption attached?                         YES                          NO

SECTION 5. VERIFICATION:
I, __________________________________, do solemnly swear or affirm under the penalties of perjury that:

A. each employee conducting origination activities in the State of Indiana on behalf of the exempt loan broker is listed on Schedule A of this
form; and
B. the information appearing in this form and the attached documents hereto is true, accurate, and complete to the best of my knowledge.

 Signature


 Title                                                                  Date (MM/DD/YYYY)


                                 CLAIM OF EXEMPTION CHECKLIST
CHECK        THE FOLLOWING INFORMATION MUST BE COMPLETED OR ATTACHED TO THIS FORM
HERE
             $200.00 fee
             Section 1 – Type of Exemption Being Claimed: Checked what type of exemption(s) the exempt loan broker is claiming.
             Section 2 – Name and Contact Information: Provided the following:
                  • Full legal name(s) of the exempt loan broker (Section 2(A))
                  • Principal Office Address (Section 2(D))
                  • Telephone Number (Section 2(f))
                  • Contact Employee (Section 2(H))
             Section 3 – Business Entity Information:
                  • Exempt loan broker and any assumed name(s) are properly registered with the Indiana Secretary of State,
                       Business Services Division; and
                  • Provided the following information:
                      • Exempt loan broker’s legal status;
                      • Exempt loan broker’s fiscal year end; and
                      • Formation information
             Section 4 – Evidence Supporting Claim of Exemption: Exempt loan broker has provided the required evidence supporting
             the claim of exemption.
             Section 5 – Verification: Signed and dated
             Schedule A – Originators: Provided the required information for each employee that is engaging in origination activities
             in the State of Indiana.
             Schedule B – Branch Office Locations: Provided the following:
                  • The required information for each office location that is either located or engaging in origination activities, in
                       the State of Indiana.
                   • Evidence showing that the exemption claimed extends to each of the branch office locations identified.




                                REST OF PAGE INTENTIONALLY LEFT BLANK




State Form 53265 (R3 / 4-08) / Form LB 5                                                                                    Page 5 of 7
                                                         SCHEDULE A
                                                         ORIGINATORS
Exempt Loan Broker’s Full Legal Name



(A) Full Name of Originator                   ADDITION              TERMINATION

 Last Name                                  First Name                             Middle Name

Date of Birth (MM/DD/YYYY)

Business Address of Originator

City                             State                         Zip+4/Postal Code     Business Telephone Number



(B) Full Name of Originator                  ADDITION               TERMINATION

 Last Name                                  First Name                             Middle Name

Date of Birth (MM/DD/YYYY)

Business Address of Originator

City                             State                         Zip+4/Postal Code     Business Telephone Number



(C) Full Name of Originator                  ADDITION               TERMINATION

 Last Name                                  First Name                             Middle Name

Date of Birth (MM/DD/YYYY)

Business Address of Originator

City                             State                         Zip+4/Postal Code     Business Telephone Number



(D) Full Name of Originator                   ADDITION              TERMINATION

 Last Name                                  First Name                             Middle Name

Date of Birth (MM/DD/YYYY)

Business Address of Originator

City                             State                         Zip+4/Postal Code     Business Telephone Number




                                           USE ADDITIONAL FORMS AS NEEDED


State Form 53265 (R3 / 4-08) / Form LB 5                                                                Page 6 of 7
                                                  SCHEDULE B
                                            BRANCH OFFICE LOCATIONS
Exempt Loan Broker’s Full Legal Name



(A) Name(s)

Address of Branch Office

City                                       State                      Zip+4/Postal Code

Telephone Number



(B) Name(s)

Address of Branch Office

City                                       State                      Zip+4/Postal Code

Telephone Number



(C) Name(s)

Address of Branch Office

City                                       State                      Zip+4/Postal Code

Telephone Number



(D) Name(s)

Address of Branch Office

City                                       State                      Zip+4/Postal Code

Telephone Number



(E) Name(s)

Address of Branch Office

City                                       State                      Zip+4/Postal Code

Telephone Number


                                       USE ADDITIONAL FORMS AS NEEDED
State Form 53265 (R3 / 4-08) / Form LB 5                                                  Page 7 of 7

				
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