I agree to make through you, in name of _________ company, whom you represent, a loan of $_____ for a term of _________ years, principal payable _________ percent amount loan annually beginning at end of _________ year. Interest on the loan accepted here shall commence with the date of the check or draft sent in settlement or on account of loan, to bear interest at the rate of _________ percent, per year, payable semiannually, to be secured by a first mortgage on real estate described, principal and interest to be payable at such place and in such manner as the lender may direct. The real estate upon which I desire this mortgage loan is as follows: _________.

In addition to the interest agreed on, I agree to pay you as a commission for negotiating the loan $_____.

I further agree to pay all expenses for abstract of title to the property offered as security in my application; also the fee for recording the mortgage and each and every instrument necessary to clear the title of all encumbrances and perfect title in me. I also agree to pay for a photograph of the premises and an attorney's fee for examination of the title.

I agree to pay such actual expenses as you have incurred in the negotiation of the loan and examination of the property and title, if I do not obtain the loan, by reason of defects in the title or by reason of my being unable to remove all encumbrances from the property, and if you or any one whom you may designate shall notify me of your acceptance of the loan and I am unable or refuse to complete the loan, then I agree to pay the above commission and all expenses you or the assignee of this contract may have incurred, for such refusal or inability to complete the loan.

I authorize you to pay off all liens and encumbrances of whatever kind now on my property described and if the loan applied for should not be sufficient to pay off all prior liens, I agree to pay the deficiency within _________ days after being notified of same.

I agree to insure, with fully paid policies, the buildings on the premises, in the sum of at least $_____ with loss, if any, payable to the lender as lender's interest may appear, all new and renewal policies to be placed by _________ in companies acceptable to them.

In event proceeds of loan are to be paid out before building is completed or as work on building progresses, I agree to furnish the usual surety bond protecting lender against all mechanics or other statutory liens, the bond to be placed by _________ in companies acceptable

In witness, etc.