State Form 53265/form Lb 5 - Claim Of Exemption Page 2
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7B. SECTION INSTRUCTIONS (cont.)
Section 2 - NAME AND CONTACT INFORMATION:
Complete each line. The name on file will appear exactly as reported in 2(A). All correspondence will be sent to the address
reported in 2(B). List the full legal names under which loan broker business will be conducted in the State of Indiana (NOTE:
the evidence submitted supporting the claim of exemption must reflect all of the exempt loan broker’s full legal names under
which loan broker business will be conducted). The individual listed as the contact employee must be authorized to receive all
compliance and licensing information, communications, and mailings, and be responsible for disseminating it within the exempt
loan broker’s organization.
Section 3 – BUSINESS ENTITY INFORMATION:
Check the appropriate box and complete the additional information requested.
When you submit this form you are affirming that:
A. All information is true and complete;
B. A business entity required to file reports with the Business Services Division of the Secretary of State’s office is current
in the filing of the reports; and
C. A business entity formed in a state other than Indiana has properly qualified to do business in Indiana.
You may want to confirm the status of your business entity and assumed names (if applicable) by contacting the Indiana
Secretary of State, Business Services Division, at or (317) 232.6576.
Section 4 – EVIDENCE SUPPORTING CLAIM OF EXEMPTION
Check the box that applies. The evidence submitted supporting the claim of exemption must reflect the full legal name of the
exempt loan broker, any “dba’s,” under which loan brokerage business is to be conduced, and the current address of the exempt
loan broker.
Section 5 – VERIFICATION
By signing the verification, the exempt loan broker is affirming that the information appearing in this form is true and complete.
Schedule A – ORIGINATORS
List the full legal name, date of birth, business address, and business telephone number for each employee conducting
origination activities in Indiana. To notify the Securities Division of new originators, check the “Addition” box. To notify the
Securities Division of the termination of an originator, check the “Termination” box. The Exempt Loan Broker Must notify the
Securities Division of the addition/termination of originators as they occur.
Schedule B – BRANCH OFFICES
List the address, telephone number, and name (if different from 2(A)) of each branch office located or engaging in origination
activities in Indiana. Exempt loan broker must submit evidence that shows the claim of exemption extends to each branch
office listed.
C. EXPLANATION OF TERMS
CONTACT EMPLOYEE – The individual authorized to receive all compliance and licensing information,
communications, and mailings, and be responsible for disseminating it within the exempt loan broker’s organization.
EXEMPT LOAN BROKER – Any person authorized to: (1) sell and service a loan for the Federal National Mortgage
Association (“Fannie Mae”) or the Federal Home Loan Mortgage Association (“Freddie Mac”), (2) issue securities
backed by the Government National Mortgage Association (“Ginnie Mae”), (3) make loans insured by the United
States Department of Housing and Urban Development (“HUD”) or the United States Department of Agriculture Rural
Housing Service (“USDA”), (4) act as a supervised lender or non-supervised automatic lender of the United States
Department of Veterans Affairs (“VA”), (5) or act as a correspondent of loans insured by the United States Department
of Housing and Urban Development (“HUD”), if the person closes at least twenty-five (25) such insured loans in
Indiana during each calendar year.
ORIGINATOR – A person engaged in origination activities.
ORIGINATION ACTIVITIES - Means communication with or assistance of a borrower or prospective borrower in
the selection of loan products or terms.
PROOF OF EXEMPTION – see attached “Required Proof for Filing an Exemption” on page 3 of this notification
form.
PERSON – An individual, a partnership, a trust, a corporation, a limited liability company, a limited liability
partnership, a sole proprietorship, a joint venture, a joint stock company, or another group or entity, however organized.
State Form 53265 (R3 / 4-08) / Form LB 5
Page 2 of 7
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