Debt Management Act Business History Form {FIS-0512}

Debt Management Act Business History Form PLEASE NOTE: This form MUST be completed for each officer, director, partner, proprietor, and member. (Note: This form is not required to be completed by a director or its equivalent if he/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.) Make copies as needed. Name Address Debt Management Firm U.S. Citizen Date of Birth / / Employment Date / / Position with this Firm FIS 0512 (08/16) Department of Insurance and Financial Services Page 1 of 3 YES NO List your employment for the last ten years starting with current position. Account for all time (if unemployed, disclose and provide dates). Name of Employer and Complete Address Position Held Month From Year Month To Year List all home addresses for the past ten years starting with present address. Attach additional pages in necessary. Number and Street City State From To Present American LegalNet, Inc. www.FormsWorkFlow.com Debt Management Act Business History Form FIS 0512 (08/16) Department of Insurance and Financial Services Page 2 of 3 Answer each question. If you answer "yes" to any of the following, please attach complete details. YES NO Have you been adjudicated as bankrupt or were you ever a partner, director, officer, member or manager of any firm or company which was adjudicated as bankrupt or for which a receiver was appointed whether during the time or within one year after you were connected with it? Have you been the subject of receivership proceedings? Have you made an assignment for the benefit of creditors? Have you been convicted of a misdemeanor or a felony (excluding motor vehicle traffic misdemeanors)? Have you been refused any license by the Department of Insurance and Financial Services or any other governmental body? Have you had any license suspended or revoked? Have you had application for license withdrawn? Have you been charged in any suit with any fraudulent or dishonest acts in any transaction? Have you been involved in any civil litigation arising out of the debt management business? Have you defaulted in the payment of money collected for others? Is there any litigation pending against either yourself or any firm or company of which you are now a partner, officer, director, member, or manager? YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO American LegalNet, Inc. www.FormsWorkFlow.com FIS 0512 (08/16) Department of Insurance and Financial Services Page 3 of 3 Debt Management Act Business History Form Section 6 of the Debt Management Act requires the Director to evaluate the applicant's experience in the licensed area. Please describe below the experiences that helped to qualify you to work in the debt management industry. Attach additional pages as necessary, a resume may also be attached. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ I do hereby certify that the above information is true and correct: Signature Date 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. When complete, please mail to: Our delivery address is: DIFS - Consumer Finance PO Box 30220 Lansing MI 48909-7720 DIFS - Consumer Finance 530 W. Allegan Street, 7th Floor Lansing MI 48933 American LegalNet, Inc. www.FormsWorkFlow.com