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Form Il 505-0335 - Application For A Real Estate Branch Office/form 505-0341 - Consent To Examine And Audit Special Accounts - 2013 Page 2

Important Notice:

Completion of this

CONSENT TO EXAMINE AND AUDIT SPECIAL ACCOUNTS

form is necessary to accomplish the

requirements outlined in the Illinois Real

Illinois Department of Financial and Professional Regulation

Estate License Act of 2000 {225 ILCS

Division of Professional Regulation/Real Estate Professions Section

454}. Disclosure of this information is

REQUIRED. Failure to comply may result

320 West Washington Street

in this form not being processed. This form

Springfield, IL 62786

has been approved by the Agency Forms

Real Estate Licensing 855/445-7763

Coordinator.

I have one or more special accounts, and authorize a representative of the Illinois Department of Financial and Professional Regulation to examine

those accounts. (Please complete both Parts A and B of this form.)

I do not accept escrow monies, and do not hold monies belonging to others. Therefore, I do not maintain any special accounts.

(Please complete only Part A of this form.)

PART A: SPONSORING BROKER INFORMATION

1. Name of Individual Managing Broker (Sole Proprietor), Partnership, Corporation, or Limited Liability Company

2. Business Address (Street, City, State, Zip Code)

3. Telephone Number ( _ _ _ ) _ _ _ - _ _ _ _

4. License Number

PART B: DEPOSITORY AT WHICH REAL ESTATE SPECIAL ACCOUNT(S) ARE MAINTAINED. A separate Consent to Audit form is required

for each depository at which you maintain special account(s). Copy this form as needed.

1. Name and address of Bank or Savings and Loan Association

2. Specific Special Accounts to be Examined and Audited

Title(s) of Special Account(s)

Account Number

Identifying Number(s)

Required by IRS

(FEIN or Social Security No.)

3. List Those Persons Authorized to Withdraw Funds From the Above-Named Special Account

Sex

Name

Title

License Number

I hereby authorize the above named-depository to allow, at any time, a duly authorized representative of the Department of Financial and Professional

Regulation to examine and audit the above named special account(s). I am one of the individuals listed under Part B(3) above.

Signature of Managing Broker

License Number

Date

Title

IL 505-0341 (Rev 3/13)

320 WEST WASHINGTON STREET • SPRINGFIELD, ILLINOIS • 62786 • PHONE: 855-445-7763 • FAX: 217-782-3390 • TDD: 217-524-6644

Form Il 505-0335 - Application For A Real Estate Branch Office/form 505-0341 - Consent To Examine And Audit Special Accounts - 2013 Page 2

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