Statement of Accountability

STATEMENT OF ACCOUNTABILITY

The undersigned licensee hereby undertakes responsibility for the activities, authorized by Massachusetts General Laws chapter 255E and its implementing regulations at 209 CMR 42.00 et seq., and engaged in by its associates listed below on behalf of the undersigned as if such associates were employed by the undersigned. It is fully understood and agreed that the Division of Banks (“Division”) may take regulatory action, as set forth in M.G.L. c. 255E and its implementing regulations, against the undersigned for the activities of its associates which are not in conformance with said chapter 255E and the regulations promulgated thereunder. If the working relationship with an associate is terminated, the undersigned will notify the Division in writing immediately.

The undersigned is responsible for maintaining a record of all associates which will include, among other things, the date the relationship was established and the date of termination. This record shall be available for review during the on-site examination of the licensee by the Division.

______

NAME OF ENTITYLicense No.

By: ______

(Signature)

______

(Name and Title)

ASSOCIATES INCLUDED IN STATEMENT OF ACCOUNTABILITY

NAMESOCIAL SECURITY NUMBER

______- ______- ______

______- ______- ______

______- ______- ______

______- ______- ______

______- ______- ______

ACKNOWLEDGMENT

State______

Date

County______

Then personally appeared before me ______and acknowledged the foregoing to be his/her free act and deed.

______

Notary Public

NOTE: If the entity undertaking accountability is a corporation, the entity must submit a certified resolution of the board of directors authorizing the officer signing the Statement to take such corporate action.

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EXEMPTION AFFIDAVIT

PURSUANT TO GENERAL LAWS CHAPTER 255E §2

I hereby acknowledge that a licensee in good standing under the regulatory jurisdiction of the Division of Banks ("Division") has executed a Statement of Accountability undertaking responsibility for the activities, as authorized by Massachusetts General Laws chapter 255E and its implementing regulations at 209 CMR 42.00 et seq., and engaged in by me on behalf of said licensee pursuant to the provisions of said chapter 255E §2.

I hereby certify that I will engage in such activities permissible under said chapter 255E and the regulations promulgated thereunder, as my primary occupation, only on behalf of the herein named licensee who has completed a Statement of Accountability and filed same with the Division. I hereby acknowledge that if any such activities are performed by me on behalf of any other entity, whether such entity is licensed or unlicensed, or in any other capacity except as herein described, I will be required to obtain a license from the Division pursuant to the provisions of chapter 255E and agree to apply for and obtain an individual license prior to engaging in any activities outside of the scope of this exemption.

Signed under the pains and penalties of perjury this ____ day of ______, 200__.

______

Name (print/type)Signature

______

Address where above named individual will conduct business

Licensee on Statement of Accountability: ______

License Number: ______

ACKNOWLEDGMENT

State ______

Date

County______

Then personally appeared before me ______and acknowledged the foregoing to be his/her free act and deed.

______

Notary Public

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