*Required field
FIS 1077 (01/17) Department of Insurance and Financial Services
Authorized by 1987 PA 173, as amended. Required for supervisory purposes and the establishment of the annual operating fee.

Mortgage Brokers, Lenders, and Servicers Annual Report
for the Calendar Year Ended December 31, 2016

Due Date: March 1, 2017

WARNING: Failure to file an annual report will result in commencement of administrative action against the license/registration. All questions refer only to loans brokered, originated, or serviced under the Mortgage Brokers, Lenders, and Servicers Licensing Act (MBLSLA), 1987 PA 173, as amended.

Any false statement, misrepresentation, or fraud in connection with this report may be cause for revocation, suspension, or other disciplinary action against the company's mortgage broker, lender, or servicer license/registration.
 
 
 

NOTE: The information provided in response to the following question will be used to determine the licensee/registrant's operating fee assessment, pursuant to Section 8(3)(b) of the MBLSLA, for the licensing year beginning January 1, 2018. The information provided should pertain only to first mortgage loans secured by Michigan property that are subject to the MBLSLA. (Refer to Section 1a(r) of the MBLSLA for the definition of mortgage loan.) Including loans secured by property in other states can result in an inappropriately high operating fee assessment. All spaces must be completed; indicate "0" if a response does not apply. Failure to provide all of the following information or to submit the annual report by March 1, 2017 may result in a maximum operating fee assessment, and it will subject the licensee/registrant to a penalty for late filing.

For the year ended December 31, 2016, state the NUMBER (#) and WHOLE DOLLAR AMOUNT ($) of:

a. First Mortgage loans brokered during 2016 (The date of loan closing determines the year of the activity. Do NOT include here a loan that closed in the name of the licensee/registrant.)
#
$
b. First mortgage loans closed in the name of the licensee/registrant during 2016.
#
$
c. First mortgage loans serviced by the licensee/registrant as of December 31, 2016, including those serviced on behalf of another.
#
$

Certification

By including the identification number, the person submitting this report hereby certifies that he/she is authorized to submit this report and has read and knowingly made the statements and representations on this report and that each and every such statement and representation is true, accurate and complete to the best of his/her knowledge and belief. He/She understands that any false statement, misrepresentation, or fraud in connection with this report may be cause for revocation, suspension, or other disciplinary action against the company's first mortgage broker, lender, or servicer license or registration.