State Form 53265/form Lb 5 - Claim Of Exemption
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7CLAIM OF EXEMPTION
State Form 53265 (R3/4-08) / Form LB 5
Approved by State Board of Accounts, 2007
Explanation and Instructions
A person claiming an exemption from the licensing and registration requirements of the Indiana Loan Broker Act pursuant to
Indiana Code § 23-2-5-19(a)(8) must file this claim with the Indiana Secretary of State, Securities Division. Before completing
this form, you should read and be familiar with the Indiana Loan Broker Act, codified in Indiana Code Chapter 23-2-5 and the
rules relating to the Act which are contained in Indiana Administrative Code Chapter 710 IAC 1-22. You may access the
statutes and rules through the Division’s website:
This properly completed form must be accompanied by:
•
$200 non-refundable fee, payable to the “Indiana Secretary of State”;
•
Names of all employees conducting origination activities in Indiana;
•
List of the address(s) of all branch offices located, or engaging in origination activities in Indiana; and
•
Evidence supporting the claim of exemption.
•
DO NOT include the instructions (pages 1-3 of this form).
A PERSON WHO KNOWINGLY FILES WITH THE COMMISSIONER ANY DOCUMENT OR STATEMENT THAT
CONTAINS A FALSE REPRESENTATION OF A MATERIAL FACT IS SUBJECT TO THE IMPOSITION OF A CIVIL
PENALTY OF UP TO $10,000 PER VIOLATION; AND CHARGED WITH A CLASS C FELONY WHICH IS
PUNISHABLE BY A FINE UP TO $10,000 PER VIOLATION AND UP TO EIGHT (8) YEARS OF IMPRISONMENT.
If the space provided for any answer is inadequate, complete your answer on a separate sheet, specifying the question to which
it relates and attach this sheet to the application. For each additional sheet you provide, sign and list the exempt loan broker’s
name.
Submit the properly completed form along with any supporting documentation to the following address:
Indiana Secretary of State
Securities Division
302 W. Washington St., Room E – 111
Indianapolis, Indiana 46204
THE INDIANA SECRETARY OF STATE, SECURITIES DIVISION HAS NOT IN ANY WAY PASSED UPON THE
ACCURACY OR ADEQUACY OF THIS CLAIM OF EXEMPTION FROM INDIANA CODE 23-2-5. ANY
REPRESENTATION TO THE CONTRARY IS A CRIMINAL OFFENSE.
A. GENERAL INSTRUCTIONS
1. TERMS USED – See the following Explanation of Terms section regarding italicized words/phrases used throughout
this State Form 53265/Form LB 5.
2. AMENDMENTS – Pursuant to Indiana Code § 23-2-5-19(e) the exempt loan broker must notify the Indiana Secretary
of State, Securities Division of a change in any information contained in this form by submitting amendments using
State Form 53265/Form LB 5. Check the “Amendment” box, complete the Sections 2(A) and 5, and, circle (or
otherwise identify) and complete the item(s) being amended. For name and/or address amendments, the exempt loan
broker must submit the required evidence listed on page three (3) of this form reflecting the new full legal name and/or
address.
3. TERMINATE / CANCEL– When an exempt loan broker decides to cease operations under the exemption, use the
State Form 53265/Form LB 5 to notify the Indiana Secretary of State, Securities Division by checking the
“Terminate/Cancel” box and completing only Sections 2(A) and 5.
B. SECTION INSTRUCTIONS:
Section 1 – TYPE OF EXEMPTION BEING CLAIMED:
Check the box next to each type of exemption that is being claimed by the exempt loan broker.
State Form 53265 (R3 / 4-08) / Form LB 5
Page 1 of 7
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