Did you sign a contract for the Loan Broker’s services?
❏ Yes (indicate date you signed the contract):
❏ No
Before you signed a contract for the Loan Broker’s services, or before you paid anything for the Loan Broker’s services (whether or not you had
a signed contract for those services), did the Loan Broker provide you with a written description of the services to be performed and the
circumstances under which the Loan Broker would be entitled to keep or receive a fee?
❏ Yes (indicate when this was provided to you):
❏ No
Did you pay a fee to the Loan Broker before you received a binding commitment from a lender to make the loan?
❏ Yes (indicate if amount paid was solely intended to reimburse the Loan Broker for out-of-pocket expenses):
❏ No
If yes, amount of fee: Date paid and form of payment (be specific):
MISCELLANEOUS:
Have you filed an inquiry or complaint with the company, the Better Business Bureau or any other person or governmental agency?
❏ Yes
❏ No
If yes, indicate Name, Address and Telephone Number of Person or Agency, and Date:
What, if any, action has been taken?
Have you obtained private legal counsel?
❏ Yes
❏ No
If yes, indicate Name, Business Address and Telephone Number of Attorney:
ATTACH COPIES OF ANY DOCUMENTS REGARDING THIS MATTER. (Include the front and back of all canceled checks, or other evidences of
payment of the Loan Broker’s fee.)
Are you willing to be interviewed by a Securities Department investigator?
❏ Yes
❏ No
Are you willing to testify if formal proceedings are commenced?
❏ Yes
❏ No
DESCRIBE IN DETAIL ANY OTHER INFORMATION THAT MAY HELP THE SECURITIES DEPARTMENT UNDERSTAND THE AGREEMENT AND ANY
DISCUSSION BETWEEN YOU AND THE LOAN BROKER. IF MORE SPACE IS NEEDED, PLEASE ATTACH ADDITIONAL SHEETS:
Signature of Borrower Date
