FIS 0516 (04/11) Office of Financial and Insurance Regulation Debt Management Termination Notification I, ___________________________________________________ residing at_________________________________________________________ (Name) (Number) (Street) ____________________________________________________, heretofore in the employ of___________________________________________ (City) (State) (Zip) (Firm Name) ____________________________________________________, a licensee, have terminated my connection with the said employer on_________ __________________________, for the following reason: _______________________________________________________________________ effective______________________________. (Date) Signature of Counselor (If signature is not obtainable, please submit explanation.) Date LICENSEE I, ______________________________________________________, a/an _________________________________________________________ (Name) (Officer, Partner, Member or Proprietor) of ______________________________________________________, hereby state that the above named individual heretofore in our employ has (Firm Name) terminated his connection with us effective on______________________________ and I believe that the individual is/is not entitled to transfer. If (Date) you have answered in the negative, explain why: _______________________________________________________________________________ ______________________________________________________________________________________________________________________. Signature of Licensee By (Officer, Partner, Member or Proprietor) Title Date NOTE: No confirmation of this termination will be sent. 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