STATE OF MARYLAND

COMMISSIONER OF FINANCIAL REGULATION

License Amendment or Return to Active Status

Affidavit of Mortgage Loan Originator Activity

License Registration No./NMLS ID:

Dear Licensee:

The Commissioner of Financial Regulation recently received your License Amendment or Return to Active Status Application requesting permission to act as a mortgage loan originator for a new employer. Please complete this affidavit and return it to the Commissioner of Financial Regulation along with all other required information needed to complete this requested change.

1. License Registration No./ NMLS ID: ______________________________

2. Have you originated any Maryland mortgage loans since you terminated employment with the employer listed on your license or went on non-active status? NO YES

3. If you answered “NO” to question 2, skip to the affidavit.

4. If you answered yes to question 2, please attach a supplemental page listing:

a. the total number of loans originated:_____________

b. the name and full address of each company for which each loan was originated;

c. the name and address of each borrower;

d. the date each loan listed was originated; and

e. the date each loan closed.

AFFIDAVIT

I __________________________________________ state under the penalty of perjury that the information on this

(Mortgage Loan Originator Licensee)

document and the attachment (if applicable) is true, correct, and complete.

______________________________________

(Mortgage Loan Originator Licensee’s Signature)

______________________________________________, personally appearing before me, who being duly sworn

(Name of Mortgage Loan Originator Licensee)

according to law, deposes and says that the statements contained in this document are true and correct. Sworn and subscribed before me this____________ day of ______________, 20___.

STATE OF __________________, COUNTY OF __________________

Notary Public________________________________________

(Print Name)

Notary Public________________________________________

(NOTARY SEAL) (Signature)

Commission Expires_________________________

Larry Hogan Department of Labor, Licensing and Regulation Kelly M. Schulz

Governor Commissioner of Financial Regulation Secretary

Boyd K. Rutherford 500 N. Calvert Street, Suite 402 Antonio P. Salazar

Lt. Governor Baltimore, Maryland 21202-3651 Commissioner