FIS 0515 (04/11) Office of Financial and Insurance Regulation Debt Management Employment Notification COUNSELOR I, ___________________________________________________ residing at_________________________________________________________ (Name) (Number) (Street) ____________________________________________________, has begun employment as a Michigan counselor with_______________________ (City) (State) (Zip) (Firm Name) ____________________________________________________, a licensee located at_________________________________________________ (Address and City) effective______________________________. (Date) Date Signature of Counselor LICENSEE I, ______________________________________________________, a/an _________________________________________________________ (Name) (Officer, Partner, Member or Proprietor) of ______________________________________________________, hereby state that the above named individual has begun employment as a (Firm Name) Michigan counselor effective ______________________________. (Date) Signature of Licensee By (Officer, Partner, Member or Proprietor) Title Date NOTE: No confirmation of this employment will be sent to licensee. If the counselor is not eligible to transfer, your firm will be contacted. Rule 11 of the Debt Management Rules 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: OFIR PO Box 30220 Lansing MI 48909-7720 Our delivery address is: OFIR 611 W Ottawa St Lansing MI 48933-1020 American LegalNet, Inc. www.FormsWorkFlow.com