CLOSING FEE REMITTANCE FORM

Please include a fully completed copy of this form when enclosing a check for the payment of closing fees. La.R.S.39:1405.1 provides for both the collection and rebate of excess fees on a pro-rata basis. The completion of this form allows us to better identify payments for these purposes. Failure to return this fully completed form with payment will result in either the delay or the inability on our part to make rebate payments.

Date of State Bond Commission Approval: _________________________________________________________

Issuer: ____________________________________________________________________________________

Issuer: ______________________________________________________________________________________

Name of Issuer: _______________________________________________________________________________

Par Amount Sold: _____________________________________________________________________________

Application Fee: Date Paid: ___________________ Amount: ____________________

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Generation and distribution of a rebate check will be made to the Issuers and can be facilitated by use of the following information:

Rebate Check Payable to:

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Individual to Whom it is sent: ____________________________________________________________________

Mailing Address: ______________________________________________________________________________

                                ______________________________________________________________________________