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COMMISSIONER OF INSURANCE INDUSTRIAL LOAN COMMISSIONER SAFETY FIRE COMMISSIONER COMPTROLLER GENERAL INDUSTRIAL LOAN COMMISSIONER Ralph T. Huygens, Commissioner www.oci.ga.gov 2 Martin Luther King

LENDER ASSISTANT LICENSE NUMBER (if no previous application in effect) (Name of Lender) (Address of Lender) (POB Number) (City) (State) (Zip code) DECORATIONS CURRENTLY SUBMITTING ASSISTANCE APPLICATIONS (If Affiliation is listed under each category on the application, specify if that applicant is in full compliance with the requirement of the lending law) (List of Applications) (Affiliation Type) (Payment History Number, Date of Request, Credit Score, and Date of Approval) (Affiliation Status) (If Larger Loans are Listed on an Application, please add the Larger Loan information to the appropriate section) (Applicant Affiliation or Relationship) (Loan Type) (Credit Score) (Date of Approval) (Name of Bank) (Issuer, if applicable) (Number of Loan(s) in this application) (Full Financial Statement) (Loan Period) (If Larger Loan is Listed on An Application, the Larger Loan information to be added under the specific categories on the application) Note: If you have previously submitted an application for an LCA without an Affiliation, you may file a new loan application for processing to ensure accuracy of information supplied. Please provide all information required, and please indicate if the Applicant is an Affiliate or if the Applicant has not previously submitted an LCA application for Georgia Industrial Loan Act. If Affiliation is listed under each category of an LCA application, indicate if that Applicant is in full compliance with the requirements for that particular category of LCA, or if you believe that Applicant is more than 75% in compliance. Please provide information to verify the Applicant's ownership if an Applicant is an Entire Ownership.

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