Form MLA16 02/03/2014
__________________________ STATE
________________________ COUNTY Company Name: _______________________________
IN THE MATTER OF:
AFFIDAVIT
The undersigned, being first duly sworn, deposes and says that:
1. I, the qualifying individual, acting as the manager of the above referenced company applying for
licensure under N. C. Gen. Stat. § 53-244.010 et seq. (The Secure and Fair Enforcement
Mortgage Licensing Act (NC SAFE Act)), have read and understand the provisions of OCOB
Form MLA19, which is incorporated by reference.
2. On or about the date of this affidavit, the mortgage broker or mortgage lender with whom I (am)
will be employed and responsible for managing has applied for licensure under the provisions of
the NC SAFE Act pursuant to N.C.G.S. 53-244.050.
3. I understand that once licensed the company will be expected and required to comply with the
laws of North Carolina and the federal laws governing the mortgage lending business in the state
and in particular any rulings issued by the Commissioner which affect mortgage lenders or
brokers.
4. I further understand that I, as the responsible person supervising the operations of this company
within the state of North Carolina, will be personally responsible for ensuring that the company
complies with the applicable laws and rules affecting the mortgage business.
5. I further understand that in the event that the company fails to comply with those statutes and
rules, the company and I, as well as any partners, owners, officers, directors, and other persons
occupying a similar status, may be subject to disciplinary action, including the assessment of civil
penalties pursuant to N.C.G.S. § 53-244.116.
FURTHER, AFFIANT SAYETH NAUGHT:
This _____ day of _________, 20___. _____________________________________ (SEAL)
AFFIANT
________________________________ STATE, _____________________________ COUNTY
I certify that: ________________________, personally appeared before me this day, and, after
being duly sworn, acknowledged to me that he/she voluntarily signed the foregoing document for the
purpose stated therein and in the capacity indicated above.
I have personal knowledge of the identity of the individual and the office he/she holds with the above
named company.
Date: _________________ __________________________________________
Notary Public signature
My commission expires: ___________________
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