Illinois > Secretary Of State > Blue Sky > Securities Department > Investigations
Borrower Statement - Illinois
| Borrower Statement Form. This is a Illinois form and can be used in Investigations Securities Department Blue Sky Secretary Of State . |
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Illinois Secretary of State Securities Department Jefferson Terrace, Ste. 300 A, 300 W. Jefferson St.Loan Broker Springfield, IL 62702 217-782-2256Borrower Statement 69 W. Washington St., Ste. 1220 Chicago, IL 60602 312-793-3384 800-628-7937 By completing this statement you will be assisting the Illinois Securities Department with the inquiry of a Loan Broker. The information received will enable the Securities Department to conduct a more accurate inquiry. BORROWER INFORMATION: Name: Age: Address: City: State: ZIP: Home Telephone Number: Work Telephone Number: Please indicate the most convenient day to be contacted: ? Monday ? Tuesday ? Wednesday ? Thursday ? Friday Please indicate the most convenient time and place to be contacted: ? Work (indicate time): ? Home (indicate time): INQUIRY REFERENCE TO: Name of Loan Broker: Address: City: State: ZIP: Telephone Number: Internet Address: Name, Address, Telephone Number and E-mail Address (if known) of person you dealt with: Title or Position the person stated he/she held: TRANSACTION INFORMATION: Describe how you contacted or were contacted by the Loan Broker: Describe the loan you hoped to obtain and why you wanted it: Did the Loan Broker promise to obtain this loan for you or to help you obtain this loan? ? Yes ? No American LegalNet, Inc. www.USCourtForms.com Printed by authority of the State of Illinois. May 2005 100 SEC 322 <<<<<<<<<********>>>>>>>>>>>>> 2Did you sign a contract for the Loan Brokers services? ? Yes (indicate date you signed the contract): ? No Before you signed a contract for the Loan Brokers services, or before you paid anything for the Loan Brokers services (whether or not you hada signed contract for those services), did the Loan Broker provide you with a written description of the services to be performed and thecircumstances under which the Loan Broker would be entitled to keep or receive a fee? ? Yes (indicate when this was provided to you): ? No Did you pay a fee to the Loan Broker before you received a binding commitment from a lender to make the loan? ? Yes (indicate if amount paid was solely intended to reimburse the Loan Broker for out-of-pocket expenses): ? No If yes, amount of fee: Date paid and form of payment (be specific): MISCELLANEOUS: Have you filed an inquiry or complaint with the company, the Better Business Bureau or any other person or governmental agency? ? Yes ? No If yes, indicate Name, Address and Telephone Number of Person or Agency, and Date: What, if any, action has been taken? Have you obtained private legal counsel? ? Yes ? No If yes, indicate Name, Business Address and Telephone Number of Attorney: ATTACH COPIES OF ANY DOCUMENTS REGARDING THIS MATTER. (Include the front and back of all cancelled checks, or other evidences ofpayment of the Loan Brokers fee.) Are you willing to be interviewed by a Securities Department investigator? ? Yes ? No Are you willing to testify if formal proceedings are commenced? ? Yes ? No DESCRIBE IN DETAIL ANY OTHER INFORMATION THAT MAY HELP THE SECURITIES DEPARTMENT UNDERSTAND THE AGREEMENT AND ANY DISCUSSION BETWEEN YOU AND THE LOAN BROKER. IF MORE SPACE IS NEEDED, PLEASE ATTACH ADDITIONAL SHEETS: Signature of Borrower Date American LegalNet, Inc. www.USCourtForms.com Printed by authority of the State of Illinois. May 2005 100 SEC 322
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