Loan Settlement Statement by _________ Savings and Loan Association

To _________[name of borrower]

_________[address]

[Date]

Your application, dated _________, for a real estate loan on property located at _________ has been approved, and we submit for your information and approval a statement of the terms of the loan, amounts received to your credit, disbursements made and expenses to be defrayed, and balance of proceeds of loan available to you.

Loan No. _________. Amount _________. Rate of interest _________. Each monthly payment of _________ is due on the _________ day of each month, beginning on [Date].

[Here state amount of loan; amounts received from borrower; amount credited to borrower's account; items, recipients, and amounts of expenses paid, with respect to credit report, survey charge, appraisal fee, title charge, legal fee, recording fee, initial service charge, mortgage tax and the like; total deductions by association for loan expenses; net amount available for purpose of loan; loan disbursements made by lender on borrower's order; amount to be paid by association to borrower as balance of loan; etc.]

In the case of a construction loan or in connection with any loan requiring a large number of disbursements or changes in the foregoing, the association will submit a detailed statement when the loan is disbursed in full.

[Signature]

Ratification by Borrower

The undersigned acknowledges receipt of this loan settlement statement, and agrees to the correctness of it, and authorizes and ratifies the disbursement of the funds as stated in it.