Maine Report Of Annual Residential Mortgage Loan Origination

Exhibit #4

State of Maine

Mortgage Loan Originator

Due on or before January 31, 2012

Report of annual residential mortgage loan origination.

Name of Mortgage Loan Originator:____________________  NMLS Unique ID #__________

Enter the number and dollar amounts of all residential mortgage transactions you originated in Maine in calendar year 2011, separating those in which you represented a supervised lender from those in which you represented a loan broker.

Type Number of loans

Dollar amount of loans
First mortgage loans
As lender:
As broker:
As lender: $
As broker: $
Second mortgages (fixed term)
As lender:
As broker:
As lender: $
As broker: $
Construction loans
As lender:
As broker:
As lender: $
As broker: $
Home equity lines of credit
As lender:
As broker:
As lender: $
As broker: $
Reverse mortgages
As lender:
As broker:
As lender: $
As broker: $
Other (describe)
As lender:
As broker:
As lender: $
As broker: $

Totals:
As lender:
As broker:
As lender: $
As broker: $

I hereby certify that the statements in the foregoing report are true and correct to the

best of my knowledge and belief.

_________________            ________________            _____________        ________

MLO Signature               MLO Name (printed)                  Employer                 Date

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