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Application for Surrender of a Mortgage Broker or Agent Licence

© Queen's Printer for Ontario, 2015

In accordance with the Mortgage Brokerages, Lenders and Administrators Act, 2006 (“the Act”), this form is to be completed by a mortgage broker or mortgage agent who wishes to apply for permission from the Superintendent of Financial Services (“the Superintendent”) to surrender his or her licence, per section 20 of the Act.

The completed and signed application should be sent to the Financial Services Commission of Ontario (FSCO) by mail to the Licensing Branch at 5160 Yonge Street, 16th floor Box 85, Toronto ON M2N 6L9, or by fax at 416-226-7838 or a scanned copy by email to contactcentre@fsco.gov.on.ca.

FSCO will review the submission and will either contact you for clarification or further information or forward it to the Superintendent for approval. If the Superintendent approves the surrender of your licence, a confirmation will be issued to you via e-mail. If the Superintendent proposes to not allow the surrender or impose conditions upon the surrender without your consent, you will be provided with written notice and given an opportunity for a hearing before the Financial Services Tribunal.

Please be advised that your licence remains valid and in force until the Superintendent has approved the surrender of the licence. Until the Superintendent has approved the surrender, you are still required to comply with all requirements of the Act and its Regulations.

Instructions

Declaration

I, Full Legal Name

wish to surrender the above-noted licence to the Superintendent and do hereby make the following Declaration in support of my request to surrender my licence under section 20 of the Mortgage Brokerages, Lenders and Administrators Act, 2006, (the “Act”) and state that the information in this Declaration is true, accurate and complete.

,

Licence #:Mortgage Agent Licence

Mortgage Broker LicenceIn relation to my

Financial Services Commission of Ontario 5160 Yonge Street, Box 85 Toronto ON M2N 6L9

Approved by the Superintendent of Financial Services pursuant to the Mortgage Brokerages, Lenders and Administrators Act, 2006

I declare that:

1. I am surrendering my mortgage broker or agent licence for the following reason(s): (Select one or more reasons, as applicable):

no mortgage brokering business was ever conducted

I have retired from the mortgage brokering business

I do not require a licence, as I will not conduct mortgage brokering activities in the future

I have transferred all my mortgage business to another mortgage brokerage, broker or agent

Other Specify, if applicable

Effective Date (yyyy-mm-dd)

Effective Date (yyyy-mm-dd)

Email Address:Telephone Number:

Mailing Address Unit/Suite Number

City Province Postal Code

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No deeds, instruments, agreements and any other documents relating to my work as an broker/agent in the business of dealing or trading in mortgages have been retained by me; all such documents, to the best of my knowledge, have either been returned to clients of the brokerage named in paragraph ii or remain in the possession of the brokerage.

3.

I have not conducted any mortgage activity except for activity conducted on behalf of the mortgage brokerages that were affiliated with my above-noted licence. My current or most recent brokerage is:

2.

Except for any circumstances in which a client has specifically requested that I do so, I have not retained the personal information of any clients of the brokerage and I will not use any such information for any purpose or release that information to any person or institution, except as required by Law.

4.

I have not done or omitted to have done anything that might reasonably be expected to have resulted in the brokerage on whose behalf I have been authorized to deal or trade in mortgages having contravened or having failed to comply with any requirement established under the Act, with the exception of the following:

I have not received, directly or indirectly, any fee or other remuneration for dealing or trading in mortgages from a person or entity other than the brokerage on behalf of which I was authorized to deal or trade in mortgages, with the exception of the following:

9.

Brokerage name

5. With the exception of printed materials currently in circulation, within five (5) days of the approval of this surrender, I will remove and/or destroy all public relations materials which identify me as a mortgage agent/ broker.

Public relations materials currently in circulation were in accordance with the Act and its Regulations at the time they were created and distributed, and they contain no false, misleading or deceptive information.

6.

If Yes, please explain.

No

Yes

Do you have any outstanding fees, charges, notices of proposal or penalties payable under the Act?10.

Please include any additional information deemed relevant to this request to surrender your licence.11.

7

If Yes, please explain.

No

Yes

Are you currently subject to any investigation by FSCO or any other regulatory body?8.

Brokerage Licence number

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For Principal Brokers Only(Please select the situation that applies to your brokerage)

The brokerage for which I am the Principal Broker:

Has had its licence revoked, has been allowed to surrender its licence, or has submitted the form to surrender its licence and is awaiting acceptance of the surrender from the Superintendent

Has appointed another principal broker and notified the Superintendent as required.

Has not notified the Superintendent of the appointment of another principal broker.

Date (yyyy-mm-dd)Applicant Signature

Applicant Name (print)

Name (print)

By Delegated Authority from the Superintendent of Financial Services, Financial Services Commission of Ontario.

Date (yyyy-mm-dd)

I understand that providing false, misleading or incomplete information on this Declaration and any attachment is an offence under the Act and may result in prosecution or regulatory sanctions.