Borrower's Request Form

BORROWER'S REQUEST FORM

Borrower Name:     Lender Name:

Loan Number:     Request Date:

RECITALS

WHEREAS, Borrower represents that Borrower executed the loan documents identified by Loan Number: dated ; and

WHEREAS, Borrower requests the action described in this Borrower's Request Form (the "Request") and Lender is authorized under the loan documents to approve, deny or conditionally approve such requests subject to the terms and conditions herein; and

WHEREAS, the parties desire to document Borrower's request, the scope of the requested action, payment terms applicable to any new disbursement or modification, and related certifications and acknowledgements.

SCOPE OF WORK / REQUEST DESCRIPTION

REQUEST DETAILS

Request Type: Disbursement Modification of Terms Payoff Statement Release of Collateral Other   If Other, specify:

Requested Amount:     Requested Disbursement Date:

Financial statements Title / lien documents Insurance certificates Other   If Other, describe:

PAYMENT TERMS

Payment Amount (if applicable):

Payment Schedule:

Late Fee/Default Interest: . All amounts due under this Request are payable in immediately available funds and are subject to the terms of the underlying loan documents.

TERM AND TERMINATION

Effective Start Date:     Anticipated End Date:

Termination: Either party may terminate consideration of this Request by providing written notice to the other party at least days prior to the proposed termination date; however, any termination is subject to the rights and remedies provided in the loan documents and does not relieve Borrower of obligations incurred prior to termination.

CONFIDENTIALITY

The parties acknowledge that information exchanged in connection with this Request may include confidential and proprietary information. Each party shall maintain the confidentiality of such information and shall use such information only to evaluate and effectuate the Request, except as otherwise required by law or by the terms of the loan documents. Borrower acknowledges that Lender may disclose information to affiliates or third parties for purposes of underwriting, servicing, or enforcement.

Borrower acknowledges and agrees: I acknowledge and will comply with confidentiality obligations.

GOVERNING LAW

This Request and any actions taken in connection with it shall be governed by and construed in accordance with the laws of the state of without regard to conflicts of law principles.

ENTIRE AGREEMENT

This Borrower's Request Form, together with the loan documents referenced herein, constitutes the entire agreement between the parties with respect to the subject matter of the Request and supersedes all prior and contemporaneous proposals, negotiations and agreements, whether written or oral, relating to the Request. No amendment to this Request shall be effective unless in writing and signed by both parties.

BORROWER CERTIFICATIONS

By submitting this Request, Borrower certifies that all information provided is true, complete and accurate to the best of Borrower's knowledge; that funds requested will be used only for the purpose(s) stated herein; and that Borrower is not in default under the loan documents except as fully disclosed to Lender in writing. Borrower further authorizes Lender to verify the representations contained in this Request and to obtain such additional information as Lender deems necessary to process the Request.

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