State Form 53265/form Lb 5 - Claim Of Exemption Page 6
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7SCHEDULE A
ORIGINATORS
Exempt Loan Broker’s Full Legal Name
(A) Full Name of Originator
ADDITION
TERMINATION
Last Name
First Name
Middle Name
Date of Birth (MM/DD/YYYY)
Business Address of Originator
City
State
Zip+4/Postal Code
Business Telephone Number
(B) Full Name of Originator
ADDITION
TERMINATION
Last Name
First Name
Middle Name
Date of Birth (MM/DD/YYYY)
Business Address of Originator
City
State
Zip+4/Postal Code
Business Telephone Number
(C) Full Name of Originator
ADDITION
TERMINATION
Last Name
First Name
Middle Name
Date of Birth (MM/DD/YYYY)
Business Address of Originator
City
State
Zip+4/Postal Code
Business Telephone Number
(D) Full Name of Originator
ADDITION
TERMINATION
Last Name
First Name
Middle Name
Date of Birth (MM/DD/YYYY)
Business Address of Originator
City
State
Zip+4/Postal Code
Business Telephone Number
USE ADDITIONAL FORMS AS NEEDED
State Form 53265 (R3 / 4-08) / Form LB 5
Page 6 of 7
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Parent category: Legal