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State Form 18542 (R3 / 6-06) Approved by State Board of Accounts, 2006

State of Indiana DEPARTMENT OF FINANCIAL INSTITUTIONS 30 South Meridian Street, Suite 300 Indianapolis, Indiana 46204

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DFI ID #

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INVOICE #_________________CHECK #_________________ AMT. PD.___________________BAL. DUE________________

APPLICATION FOR LOAN LICENSE
ATTACH LICENSE APPLICATION FEE CHECK HERE

TO BE COMPLETED BY ALL APPLICANTS
The undersigned makes application for a loan license as provided in the Indiana Uniform Consumer Credit Code, IC 24-4.5. Name of Applicant (Sole Proprietorship, Partnership, Corporation, LLC)

PRINCIPAL BUSINESS ADDRESS: Address (Number and Street) City, State, ZIP Code HOME OFFICE NAME AND ADDRESS: Home Office Name Address (Number and Street) City, State, ZIP Code ADDRESS WHERE LICENSE IS TO BE SENT: Address (Number and Street) City, State, ZIP Code Contact Person E-Mail Telephone Fax Telephone Fax

(If Different from Principal Business Name and/or Address)

ASSUMED NAME
If applicant operates under an assumed name, a certificate from the appropriate official showing compliance with the provisions of the laws of the State of Indiana pertaining to conducting business under an assumed name is to be included with the application.

INDIVIDUALS (To be completed by those operating as a sole proprietorship)
Name Address ( Number and Street) City, State, ZIP Code Telephone

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PARTNERSHIPS (To be completed by those operating as Partnerships)
NAME AND RESIDENCE ADDRESS OF EACH PARTNER: Name Address (Number and Street) City, State, ZIP Code Name Address (Number and Street) City, State, ZIP Code ATTACH AN ADDITIONAL SHEET IF NECESSARY Telephone Telephone

CORPORATIONS / LIMITED LIABILITY COMPANIES (To be completed by those operating as a Corporation / LLC)
Name of Corporation / LLC Address (Number and Street) City, State, ZIP Code Corporation Organized Under the Laws of What State? Telephone Date of Incorporation / Organization

ATTACH A COPY OF YOUR CERTIFICATE OF AUTHORITY FROM THE INDIANA SECRETARY OF STATE.
LIST OFFICERS, DIRECTORS, OR MEMBERS OF THE CORPORATION OR LLC WITH TITLE AND RESIDENCE ADDRESS:

Name of Officer / Director / Member Address (Number and Street) City, State, ZIP Code Name of Officer / Director / Member Address (Number and Street) City, State, ZIP Code Name of Officer / Director / Member Address (Number and Street) City, State, ZIP Code ATTACH AN ADDITIONAL SHEET IF NECESSARY

Title

Telephone Title

Telephone Title

Telephone

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IF A CORPORATION OR LLC, LIST ALL PERSONS OR ENTITIES OWNING 10% OR MORE OF THE COMPANY. FOR ENTITIES MEETING THIS TEST, LIST THE PERSONS OWNING THAT ENTITY.

Name Address (Number and Street) City, State, ZIP Code Name Address (Number and Street) City, State, ZIP Code Name Address (Number and Street) City, State, ZIP Code ATTACH AN ADDITIONAL SHEET IF NECESSARY

Title

Telephone Title

Telephone Title

Telephone

Give three (3) names and addresses of references as to your "financial responsibility, character, and fitness." One shall be a representative of a depository institution. Reference letters on the reference's business stationery are to be submitted with your license application.
Individual's Name Address (Number, Street, City, State, ZIP Code) Individual's Name Address (Number, Street, City, State, ZIP Code) Individual's Name Address (Number, Street, City, State, ZIP Code) Title Telephone Title Telephone Title Telephone

REFERENCES

INDIANA BRANCH INFORMATION
ADDRESS OF EACH INDIANA BRANCH LOCATION Address (Number and Street) City, State, ZIP Code Address (Number and Street) City State, ZIP Code Address (Number and Street) City, State, Zip Code ATTACH AN ADDITIONAL SHEET IF NECESSARY Page 3 Telephone Telephone Telephone Number of Branches _______

GENERAL INFORMATION
1. If a corporation / LLC, attach a copy of your certificate of authority and articles of incorporation from the Indiana Secretary of State. 2. Will you be operating as a loan or mortgage third party broker? Yes No If Yes, attach a copy of your Indiana Loan Broker Registration from the Indiana Secretary of State, Securities Division or letter of exemption. 3. Attach a copy of your Indiana business plan including information on any other types of activities you will be engaged in. 4. (a) List other states where the applicant or any affiliated company operates as, or did operate as, or is licensed or regulated, or was licensed or registered as, a lender, loan broker, or other financial services provider under state or federal regulatory authority. Provide the same information for owners and officers of the applicant. Provide the name of all state and federal regulatory agencies, contact person, contact information, and the date licensed. (b) Applicant should obtain a letter of good standing, or equivalent, from their home state lender regulator, other than Indiana, where they are currently making loans. 5. Has the applicant, any affiliated company , or any company associated with the owners or officers of the applicant had a license or registration cancelled, suspended, or revoked in any state or been subject to a state or federal enforcement or administrative order, including but not limited to informal resolutions, memorandums of understanding, cease and desist orders? Yes No If Yes, give full details.________________________________________________________________ 6. Do you agree to keep a separate set of books and records to be used only for the lending business? Yes No 7. Do you plan to sell insurance to borrowers? Yes No If Yes, describe type/s of insurance. No

8. Do you plan to purchase retail installment sales contracts? Yes

9. Attach a detailed explanation of the following: a. How loans will be made? When will applicant be funding/brokering loans versus closing in name of applicant as "creditor"? b. Written description of the funding of the loan to the consumer. c. Security d. Estimated Average Loan. e. Are you going to make only first lien mortgage loans? Yes license. g. Will you retain servicing on the loans? Yes No No If Yes, you do not need an Indiana loan

f. Will you have a location in Indiana or will you use Indiana title companies or attorneys to close the loans? If No, who will be servicing?

h. Software the applicant proposes to use for disclosure and/or record keeping. i. Why do you wish to make loans in Indiana? j. Who will Indiana loans be sold to? Give full details. 10. Who will be managing the business?

Applicant must show minimum two (2) years finance related experience for anyone who will be managing an Indiana location.

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11. Give history and full details of any material litigation and/or criminal convictions for five years preceding date of application for any owner, partner, corporate officer, limited liability member, or branch manager. 12. Do you plan to make small loans under IC 24-4.5-7? Yes No If Yes, complete application for Small Loan License. 13. Review IC 24-9 effective January 1, 2005 regarding mortgage predatory lending. Also review IC 24-4.5-3-203.5, 3-209, 3-402 and confirm your review and understanding of all cited sections. ATTACH A BUSINESS RESUME FOR THE MANAGER, OWNER, PARTNERS, AND ALL OFFICERS, AS APPLICABLE. ATTACH CPA PREPARED REVIEWED OR AUDITED FINANCIAL STATEMENTS or most recent 10K filing with the Securities and Exchange Commission (SEC) having a minimum net worth of at least $100,000 and liquid assets of $50,000.

ACKNOWLEDGMENT
The applicant executed this application on and acknowledges that all statements made herein and supporting schedules, to the best of my/our knowledge and belief, are true and is a true and complete statement in accordance with the law. Intentionally providing false information will terminate the application process and will subject the license to revocation if false information is substantiated after issuance, IC 24-4.53-504(1)(b).

IF A CORPORATION, PRESIDENT AND ONE OFFICER MUST SIGN; IF LLC, MEMBER/S MUST SIGN; IF A PARTNERSHIP, ALL PARTNERS MUST SIGN; IF SOLE PROPRIETORSHIP, OWNER MUST SIGN. ATTACH AN ADDITIONAL SHEET IF NECESSARY. By: By: Title Title

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STATE OF INDIANA

DEPARTMENT OF FINANCIAL INSTITUTIONS
30 South Meridian Street, Suite 300 Indianapolis, Indiana 46204-2759 Telephone: (317) 232-3955 FAX: (317) 232-7655 WEB SITE http://www.in.gov/dfi

TO APPLICANTS FOR A LOAN LICENSE:

The Indiana Uniform Consumer Credit Code (IUCCC) provides that, unless a person is a supervised financial organization or has first obtained a license from the Department of Financial Institutions authorizing them to make consumer loans, they shall not engage in the business of making such loans. If taking assignment or undertaking direct collection of payments in Indiana, a loan license is also required. If making small loans under IC 24-4.5-7, the applicant must complete Small Loan License Application.

APPLICATION FOR LOAN LICENSE: The original application form is to be filed with the Department and a copy of the form
should be retained by the applicant. Only one license is needed to operate in one or more locations.

LICENSE FEE: The application must be accompanied by an initial loan license fee of $1,000. The check or money order is to

be made payable to the Department of Financial Institutions. Licenses are renewed annually with the IUCCC Creditor's Notification Return by January 31. The required license renewal fee is the greater of $1,000 or the annual volume fees paid under IC 24-4.5-6-203.

least $50,000. Liquid assets include cash or it equivalent (any assets that are readily convertible to cash without significant loss such as treasury bills, short term marketable securities, demand deposits, and time deposits nearing maturity. Other assets that are to be considered liquid must be identified by a footnote in the CPA report as to how the liquidity was determined.) CPA prepared reviewed or audited financial statements or the most recent 10K filing with the Securities and Exchange Commission (SEC) verifying the above requirements must accompany the application. Indiana location.

FINANCIAL RESPONSIBILITY: The applicant must have a minimum net worth of at least $100,000 and liquid assets of at

EXPERIENCE: Applicant must show minimum two (2) years finance related experience for anyone who will be managing an

STATE POLICE REPORT: A criminal record report from the State Police of the State of residence for each owner (sole proprietorship), partner (partnership), members (LLC), or officers (corporation) as well as the manager for an Indiana location must accompany the application. For Indiana residents, the report from the Indiana State Police may be secured by sending a money order (amount determined by State Police) to the ISP Central Records Division, IGCN 100 North Senate, Room 302, Indianapolis, IN 46204, 317-232-8262. Include your name, address, date of birth, and your finger prints and request a review of records for the Department of Financial Institutions for the issuance of a loan license. CREDIT REPORT: A credit report of the business and/or principals is to be attached to the Application. REFERENCES: Give three names and addresses of references willing to acknowledge the financial responsibility, character, and fitness of the applicant. One reference shall be a representative of a financial institution. Reference letters on the reference's business stationary should be submitted with your license application. FORMS TO BE SUBMITTED: When returning the application, you are to enclose copies of the forms listed below which will
be used in conjunction with your lending transactions. 1. Loan Application 2. Note and Security Agreement 3. Disclosure Form (If not a part of Item 2 or 3.) 4. RESPA Statement (Complete mortgage package for second mortgage loans) 5. Retail Installment Sales Contract (If applicable.)

PLEASE NOTE: The application and financial statement must be fully completed and filed with the Department along with the required initial license fee. Upon the Department's receipt of the application, an investigation may be made into the financial responsibility, character, and general fitness of the applicant. Upon granting the license, a duly authenticated and numbered license will be forwarded to the address designated in the application. The licensee should show the assigned license number in all correspondence or communications with the Department subsequent to licensing. Licenses under the Indiana Uniform Consumer Credit Code are issued on the basis of representations made in the application. Any substantial change in the information included in the application shall be reported to the Department within thirty days after such change. See IC 24-4.5-3-505(3) and 6-202(3). Change in the name requires the submission of the license to the Department for reissue. Change in ownership of the holder of the license terminates the license. Indiana loan licenses are not assignable or transferable, see IC 24-4.5-3-503(6).
CONSUMER CREDIT DIVISION [email protected]

LOAN LICENSE APPLICATION CHECKLIST
ATTACH TO APPLICATION

CHECK THE FOLLOWING MUST BE ATTACHED TO THE APPLICATION HERE
$1,000 Loan License Application Fee CPA prepared Reviewed or Audited Financial Statements or most recent 10K filing with the Securities and Exchange Commission (SEC) with a minimum $100,000 net worth and $50,000 in liquid assets State Police Report of State of residence for each principal (owner-sole proprietorship, partners ­ partnership, officers ­ corporation, members ­ LLC) Credit Report for business and/or principals Three reference letters, one must be a financial institution Example of loan application Sample of a completed filled-in Note and Disclosures applicable to type of loans to be made RESPA Statement (Complete filled-in mortgage package if making second mortgages. In particular, address provisions in IC 24-4.5-3-203.5, 3-209, and 3-402.) Retail Installment Contract (if purchasing contracts from Indiana dealers) Security agreement (if purchasing contracts from Indiana dealers) If a corporation / LLC, a copy of Certificate of Authority to do business in Indiana from the Secretary of State If a D/B/A is being used, a copy of assumed name certificate from the Indiana County recorder for each County where you do business Copy of Indiana business plan List of other states where operating as a lender and/or broker Letter of good standing, or equivalent, from Home Office State Lender Regulator Copy of your Indiana Loan Broker License if operating as a loan or mortgage third party broker in Indiana Business resume for the manager, owner, partners, members, and all officers, as applicable Detailed information requested in Item 9 on Page 4 of the application Check each item required to accompany the application to make sure your application is complete and send this checklist with the application.