This application may be used for Mortgage Guaranty Insurance Corporation and MGIC Indemnity Corporation (each, MGIC). Coverage will be assigned by MGIC to the appropriate writing company.

Lender, by its authorized representative, represents that the information provided to MGIC on this form and all additional documentation and information provided to MGIC, whether prepared or submitted by the Lender, originator (if different from Lender), borrower, appraiser or any other person or entity, is true, correct and complete. This representation is relied upon by MGIC in insuring this loan.

WARNINGS

• FL - Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
• NY - Please be informed that any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
• ME - Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or files a claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime, and may result in imprisonment, fines or denial of insurance benefits.
• MD - Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
• OR - Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or files a claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto may be committing a fraudulent insurance act, which may be a crime, and may result in imprisonment, fines or denial of insurance benefits.
• Washington, DC - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
• AR, CO, KY, LA, NH, NJ, NM, OH, OK, PA, TN and VA - Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or files a claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.