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Lender Conflict Of Interest Disclosure Statement

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Registrar of Mortgage Brokers

2800 - 555 West Hastings

Vancouver, BC V6B 4N6

Ph. 604-660-3555 / Toll-free: 1-866-206-3030 (BC)

Facsimile: 604-660-3365

Mortgagebrokers@ficombc.ca

LENDER CONFLICT OF INTEREST DISCLOSURE STATEMENT

FORM 11 – Section 17.4

This information statement has not been filed with the Registrar of Mortgage Brokers. There has been no

determination made by the Registrar as to whether the disclosed information complies with the Mortgage

Brokers Act.

Please write or print clearly. If additional information is required, reference and attach a schedule to this form.

Name of Borrower(s):

Name of Lender:

Name of Mortgage Broker:

Telephone:

Name of Submortgage Broker:

Date of transaction:

Civic address of property to be mortgaged:

Legal description of property to be mortgaged:

Mortgage Broker’s Interest in the Transaction

The Mortgage Broker and/or its associates or related parties will not acquire a direct or indirect

interest in the transaction described above.

The Mortgage Broker and/or it associates or related parties will acquire a direct or indirect

interest in the transaction described above. In particular, ____________________________

(

State the name of the party)

who is __________________________________ will:

(State the relationship with Mortgage Broker)

be a syndicate mortgage lender with the lender;

be either the registered or beneficial borrower in the transaction;

acquire the mortgage from the lender; or

___________________________________________________________________

(identify nature of interest)

Lender Conflict Of Interest Disclosure Statement

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