Il Loan Brokerage Agreement And Loan Brokerage Disclosure Statement Form Page 2

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The undersigned Borrower has read and acknowledged receipt of the Loan Brokerage Agreement. This Agreement has
been executed on the same date written below by the Borrower and the Broker.
Loan Brokerage Disclosure Statement
(38 IL Adm. Code 1050.1020)
The Borrower acknowledges by signing below that they understand the following:
1. The Broker does not make loans.
2. Actual funds are provided by another entity, which may affect availability of funds.
3. The Broker is currently licensed as: _________________________________ under the Act. During the preceding
ten (10) years, Broker has operated under the following names:
___________________________________________________________________________________________
___________________________________________________________________________________________
4. Name(s) of any parent or affiliated companies:
___________________________________________________________________________________________
___________________________________________________________________________________________
5. The Broker conducts business as: ________________________________________________________________
6. The Broker:
____ brokers loans to only one entity.
____ brokers loans to more than one entity.
THE UNDERSIGNED APPLICANT HAS READ AND UNDERSTAND THE ABOVE LOAN BROKERAGE
DISCLOSURE STATEMENT OR HAS HAD THE CONTENTS EXPLAINED BY SOMEONE NOT
CONNECTED WITH THE BROKER.
The undersigned Borrower has read and acknowledged receipt of the Loan Brokerage Agreement and the Loan
Brokerage Disclosure Statement.
____________________________________________
_____________________________________________
Borrower
Date
Borrower
Date
____________________________________________
_____________________________________________
Borrower
Date
Borrower
Date
____________________________________________
_____________________________________________
Broker Representative
Date
Broker Representative Registration Number

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