Department of Banking and Securities – Non-Depository Licensing Office 17 N 2nd St, Ste 1300 | Harrisburg, PA 17101 | 717.787.3717 | F 717.787.8773 | www.dobs.pa.gov

Surrender Form

Name of Company:

Office Type Surrendering License(s): Main Office: Branch Office(s): All:

License Number(s) (if all offices are closing, only list Main Office Number, otherwise list all closing branch license numbers:

Effective Date of Closure/Surrender:

Reason for License Surrender:

State: Zip:

Custodian of Records:

Name:

Street Address:

City:

Telephone: Fax: Email Address:

Location of Records: Street Address: City: State: Zip: Please Attach the following information on the status of each loan to Pennsylvania consumers that are outstanding: Name of Consumer Consumer Address and telephone number Current Application Status Loan Number Amount of Loan Contact information for applicable lender with who each loan will be placed Date loan will be resolved

Contact Information: Name: Title: Firm Name (if applicable): Street Address: City: State: Zip: Telephone: Fax: Email Address: I understand by submitting this Surrender Request: I am agreeing to be bound by the following declaration: "I declare that all of my answers on this Surrender Request are complete, true and correct. I make this declaration subject to the penalties of 18 PA.C.S. § 4904 relating to unsworn falsification to authorities.” Name: Title: Signature: Date:

Surrender Company: Surrender PPOB: OffSurrender Branch: OffSurrender All: OffSurrender Branch 2: Surrender Branch 3: Surrender Branch 4: Surrender Branch 5: Surrender Branch 6: Surrender Branch 7: Surrender Branch 8: Surrender Branch 9: Surrender Branch 10: Surrender Branch 11: Surrender Branch 12: Surrender Branch 13: Surrender Branch 14: Surrender Branch 15: Surrender Branch 16: Surrender Branch 17: Surrender Branch 18: Surrender Branch 19: Surrender Branch 1: Surrender Branch 20: Surrender Branch 21: Surrender Branch 22: Surrender Date: Surrender Reason: Surrender Custodian: Surrender Custodian St: Surrender Custodian City: Surrender Custodian state: Surrender Custodian Zip: Surrender Custodian phone: Surrender Custodian Fax: Surrender Custodian email: Surrender Records st: Surrender Records city: Surrender Records State: Surrender Records zip: Surrender Contact name: Surrender Contact Title: Surrender Contact Business Name: Surrender Contact St: Surrender Contact City: Surrender Contact State: Surrender Contact Zip: Surrender Contact Phone: Surrender Contact Fax: Surrender Contact Email: Surrender Authorization title: Surrender Authorization name: Surrender Authorization Date: