Debt Management Fee Processing Card {FIS-0550}

FIS 0550 (08/16) Department of Insurance and Financial Services Debt Management Fee Processing Card Instructions: Complete the Debt Management Fee Processing Card below and include it with your check. Failure to properly complete or return this card with your fees may result in a processing delay. Enter the name and Federal Employer ID Number (FEIN) or Social Security Number (SSN) of the Debt Management Firm or Debt Management Counselor on the Fee Processing Card. Include a money order, or check made payable to the State of Michigan. Do not send cash. Fees are non-transferable and non-refundable. 1975 PA 148, as amended, requires submission of this form with payment for various fees associated with debt management companies licensed or applying for a license in Michigan. Failure to file this form may result in processing delays that could delay issuance, renewal or continuation of a debt management company license in Michigan, and subject licensee or applicant to additional fees or penalties. FIS 0550 (03/15) Department of Insurance and Financial Services Debt Management Fee Processing Card Please check the fees that apply to you. Attach a check made payable to the State of Michigan. Send all other fees to Department of Insurance and Financial Services, PO Box 30220, Lansing MI 48909. Examinee name Social Security Number (SSN) Firm name If firm is an individual and has no FEIN, enter SSN Firm's Tax ID number (FEIN) Fee Type-Check all that apply Debt Management License Fee Debt Management Investigation Fee Debt Management Renewal Fee Fee Code 35 35 35 Amount Due $50.00 per office $50.00 per office $50.00 per office Number of Offices Subtotal $ ___________ $ ___________ $ _____________ ___________ ___________ _____________ Total amount enclosed American LegalNet, Inc. www.FormsWorkFlow.com