2015 Declaration Of Activity-Mortgage Broker Company Form

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STATE OF WASHINGTON
DEPARTMENT OF FINANCIAL INSTITUTIONS
DIVISION OF CONSUMER SERVICES
P.O. Box 41200
Olympia, Washington 98504-1200
Telephone (360) 902-8703
TDD (360) 664-8126
FAX (360) 664-2258
MORTGAGE BROKER COMPANY
2015 DECLARATION OF ACTIVITY
I, ________________________________________, declare:
Print Name
1.
I am above the age of eighteen and, based on my personal knowledge, am competent to testify to
the facts as stated in this declaration.
2.
I am the Designated Broker for _______________________________________________, whose
Print Company Name
Mortgage Broker Practices Act license number is MB-________________.
(NMLS number)
3.
I certify that since January 1, 2015 the Company noted in paragraph 2
has
performed any activity that would require licensure as a mortgage broker under
has not
Chapter 19.146 RCW, the Mortgage Broker Practices Act (the Act).
(Check One)
4.
I also certify that since January 1, 2015, the Company noted in paragraph 2
has
received any compensation that would require licensure as a mortgage broker
has not
Chapter 19.146 RCW, the Mortgage Broker Practices Act (the Act).
(Check One)
5.
I further certify that the Company noted in paragraph 2 will refrain from conducting any activity that
would require licensure as a mortgage broker under Chapter 19.146 RCW, until the Department
issues the Company a valid mortgage broker license for 2015.
I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and
correct.
DATED this ____ day of ______________, 2015 in ___________________, __________.
Day
Month
City
State
_____________________________________________
_________________________________
Signature
Contact Phone Number
Declaration of Activity – Mortgage Broker 2015

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