State Form 53265/form Lb 5 - Claim Of Exemption Page 7

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SCHEDULE B
BRANCH OFFICE LOCATIONS
Exempt Loan Broker’s Full Legal Name
(A) Name(s)
Address of Branch Office
City
State
Zip+4/Postal Code
Telephone Number
(B) Name(s)
Address of Branch Office
City
State
Zip+4/Postal Code
Telephone Number
(C) Name(s)
Address of Branch Office
City
State
Zip+4/Postal Code
Telephone Number
(D) Name(s)
Address of Branch Office
City
State
Zip+4/Postal Code
Telephone Number
(E) Name(s)
Address of Branch Office
City
State
Zip+4/Postal Code
Telephone Number
USE ADDITIONAL FORMS AS NEEDED
State Form 53265 (R3 / 4-08) / Form LB 5
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