Voluntary Suspension Form

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Request for suspension of
statement of record effective date

Please enter
subdivision name

Please enter
developer

Please enter
ILS number

OMB No. 3170-0012
Expiration: xx/xx/20xx

SUBDIVISION

DEVELOPER

ILS NUMBER

Pursuant to 12 CFR 1010.21(b), the developer of the above-referenced subdivision hereby requests
the suspension of the effective date of its statement of record together with all amendments and/or
consolidations filed subsequent to the initial statement of record.
The basis for granting the suspension is:
INSERT BASIS HERE

Consumer Financial
Protection Bureau

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REQUEST FOR SUSPENSION OF STATEMENT OF RECORD EFFECTIVE DATE

The developer certifies that: (i) the developer does not have any outstanding annual financial statements
required to have been filed pursuant to 12 CFR 1010.212(d) or which are under pending review with the
Bureau; (ii) the developer does not have any outstanding annual reports of activity required to have been
filed pursuant to 12 CFR 1010.310 (including outstanding fees owed under 12 CFR 1010.35) or which
are under pending review with the Bureau; or (iii) the developer is not the subject of an administrative
proceeding filed by the Bureau.
The effectiveness of the statement of record is suspended effective with the date of execution by the developer.
Please provide
the developer
and the date of
execution

DEVELOPER

DATE

Please provide
signature
PRINTED NAME

TITLE

Notice of Collection under the Privacy Act of 1974, 5 U.S.C. § 552a — As Amended (Privacy Act Notice)
The information in the system allows for the submission of information related to interstate land sales
registrations pursuant to the requirements of the Interstate Land Sales Full Disclosure Act, 90, codified at
15 U.S.C. 170, et seq. Identifying information collected may be used by and disclosed as permitted by the
Privacy Act, 5 U.S.C. § 552a, to employees, contractors, agents, and others authorized by the Consumer
Financial Protection Bureau to receive this information to assist in related activities. It may also be disclosed:
§§ To a court, magistrate, or administrative tribunal in the course of a proceeding;
§§ For enforcement, statutory, and regulatory purposes;
§§ To another federal or state agency or regulatory authority;
§§ To a member of Congress; to the Department of Justice, a court, an adjudicative body or administrative
tribunal, or a party in litigation;
§§ To the public, members of the media, federal, state, and local government officials, or other recipients of
public relations materials issued by the CFPB about the activities of the CFPB; and
§§ Pursuant to the CFPB’s published Privacy Act system of records notice, CFPB.012 – Interstate Land Sales.
The collection of this information is authorized by 12 CFR 1010. 100 – 1010.219 and the Interstate Land Sales
Full Disclosure Act, 15 U.S.C. 1701, et seq.

Consumer Financial
Protection Bureau

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REQUEST FOR SUSPENSION OF STATEMENT OF RECORD EFFECTIVE DATE

Paperwork Reduction Act
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not
required to respond to a collection of information unless it displays a valid OMB control number. The OMB
control number for this collection is 3170-0012. It expires on XX/XX/XXXX. The time required to complete this
information collection is estimated to average approximately 1 hour per response. The obligation to respond to
this collection of information is voluntary. Comments regarding this collection of information, including the
estimated response time, suggestions for improving the usefulness of the information, or suggestions for reducing
the burden to respond to this collection should be submitted to Bureau at the Consumer Financial Protection
Bureau (Attention: PRA Office), 1700 G Street NW, Washington, DC 20552, or by email to [email protected].

Instructions
This form may be used to notify the CFPB that an entity wishes to suspend its registration under the Interstate
Land Sales Full Disclosure Act, 15 U.S.C. 1701, et seq. because it is no longer engaging in the activities covered
under the statute. This form can only be used if there are no administrative proceedings pending against either
the developer or the owner at the time the request is submitted.

Consumer Financial
Protection Bureau

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