Initial Application For Debt Management License {FIS-0506}

Initial Application for Debt Management License Applicant's Name Firm's Fiscal Year End FIS 0506 (08/16) Department of Insurance and Financial Services Page 2 of 3 Applicant's Home Office Address Firm's Web Address City State ZIP Code Telephone Number ( ) Fax Number ( ) Contact Person Title E-Mail Address ADDITIONAL OFFICES (Attach additional page(s), if necessary) ADDRESS ( PHONE NUMBER ) MANAGER ( ) ( ) ( ) ( ) Type of Business Entity (check one only): Sole Proprietorship. Give name and home address. ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Partnership. Attach list of partners, showing names, home addresses, and whether general or limited partner. Corporation. Attach a list of officers, members and directors, showing names, home addresses, position held and percentage of interest held directly or otherwise. Limited Liability Company or Unincorporated Association. Attach a list of members, giving names, home addresses, positions held and percentage of interest held directly or otherwise. American LegalNet, Inc. www.FormsWorkFlow.com FIS 0506 (08/16) Department of Insurance and Financial Services Page 3 of 3 Initial Application for Debt Management License Indicate whether the applicant, its general partners, members or managers or any of the officers or directors: (Note: This question does not apply to directors or their equivalent if he or she does not receive a salary, stock dividend, or other financial benefit from the corporation or equivalent entity, other than reimbursement of the actual expenses incurred in carrying out the duties of a director of that corporation or equivalent entity.) YES YES YES NO NO NO 1. Has been convicted of a crime involving moral turpitude which includes forgery, embezzlement, obtaining money under false pretenses, larceny, extortion, conspiracy to default or any other like offenses. 2. Has been the subject of an order by the Department of Insurance and Financial Services for violating or failing to comply with a provision of the Act, Rules, or an Order promulgated or issued under the Act. 3. Has had a license to engage in the business of debt management revoked or suspended for any reason other than failure to pay the licensing fees in this state or in another state. 4. Has ever defaulted in the payment of money collected for others including the discharge of debts through bankruptcy proceedings. 5. Is associated with any other debt management business entity. If yes, please provide the name and address of the business. 6. Is operating a collection agency or affiliated with one. If yes, please provide the name and address of the agency. 7. Is a partnership, corporation, limited liability company or association which has not been granted a certificate of authority to do business in this state. 8. Is engaged in any other business professions besides debt management. If yes, provide details. YES NO YES YES NO NO YES NO YES NO If you have answered "yes" to any of the above, please attach complete details. The undersigned, _____________________________________, being first duly sworn, deposes and says: That I have executed the following application for and on behalf of the applicant named therein; that I am ____________________________________ of such applicant and fully authorized to execute and file such application; that I am familiar with such application; and that to the best of my knowledge, information and belief the statements made in such application are true and the documents submitted therewith are true copies of the originals thereof. It is fully understood by me that any misrepresentation or false statements or fraud in or in connection with this application shall be cause for revocation of the license issued thereon, in addition to any other action and/or penalty to which I may be subject. Date: __________________________ ____________________________________________ (Name of Applicant) By: ___________________________________________ (Name and Title) (Officer, Partner, Member or Sole Proprietor) 1975 PA 148 as amended requires submission of this form by applicants for a license to do business as a debt management company. Failure to complete and submit this form properly could result in denial, suspension or revocation of your license. American LegalNet, Inc. www.FormsWorkFlow.com