STATE OF CALIFORNIA DEPARTMENT OF CORPORATIONS INSTRUCTIONS FOR COMPLETING THE SHORT FORM APPLICATION FOR A LICENSE UNDER THE CALIFORNIA FINANCE LENDERS LAW (CFLL) ASSISTANCE WITH THE APPLICATION Refer to these instructions while completing the CFLL short form application. If you have questions about the application that are not answered by these instructions, call the Department of Corporations’ toll-free telephone number at (866) 275-2677. Department personnel cannot provide individual legal or accounting advice. Applicants who need such advice must consult a qualified professional. FEES AND PROCESSING OF THE APPLICATION The application and any attachments must be typewritten. The signature must be original and not a copy. Attach additional sheets if you need more space to complete an answer to any of the questions and label the answers by the corresponding question number. Answer every question in the application. A CFLL licensee seeking to engage in business at an additional location must submit this application to the California Corporations Commissioner by certified mail, return receipt requested, at least 10 days before engaging in business at the location. The application must be accompanied by a nonrefundable application fee of $200 and an investigation fee of $100. The application fee and investigation fee are not refundable if the application is denied or withdrawn. Make the check payable to the Department of Corporations for the total amount of all fees. The application, attachments, and fees must be filed only in the Los Angeles office of the Department of Corporations, located at 320 West 4th Street, Suite 750, Los Angeles, California 90013. THE CFLL SHORT FORM APPLICATION The headings used in these instructions correspond to the item numbers in the application. ITEM NUMBER 1 OF APPLICATION: Name of Applicant: Provide the applicant’s legal name. Some foreign entities are required by the California Secretary of State’s office to use an assumed name for all business they conduct in California. These entities should provide that assumed name as the “Name of Applicant” and may only use that name. These entities are not permitted to use a fictitious business name. 1423-CFLL Short Form Instructions 1 American LegalNet, Inc. www.FormsWorkflow.com Fictitious Business Name: An applicant that intends to conduct CFLL business under a fictitious business name that is different from its legal name should provide the fictitious business name here. Provide the name that appears on the Fictitious Business Name Statement as filed with the county clerk. The use of a fictitious business name is not permitted for a new location unless the Department of Corporations has already approved the use of that name. If the fictitious business name has not already been approved by the Department of Corporations, approval of a new fictitious business name may be requested from the Department of Corporations by submitting under separate cover a copy of the Fictitious Business Name Statement with the “filed stamp” from the county clerk’s office. The applicant’s name must appear as a registrant on the Fictitious Business Name Statement. This document should be forwarded along with a written request to CFLL Licensing Specialist, Department of Corporations, 320 West 4th Street, Suite 750, Los Angeles, California 90013. Applicants who intend to conduct business under a fictitious business name are required to comply with the rules governing the filing of a fictitious business name as set forth in Business and Professions Code Section 17900 et seq. ITEM NUMBER 2 OF APPLICATION: Applicant’s Licensed Place of Business: Provide the applicant’s complete proposed place of CFLL business, including number and street, city, county, state, zip code, telephone number, and fax number. ITEM NUMBER 3 OF APPLICATION: Individual in Charge of this Location: Each office must have a person who is in charge. Provide the full name of the individual who will be in charge of this location. If the applicant has no middle name, indicate, e.g. “John [no middle name] Smith.” Statement of Identity and Questionnaire: The individual named in Item Number 3 of the application must complete and submit a Statement of Identity and Questionnaire. If a Statement of Identity and Questionnaire has already been provided to the Department for the individual named in Item Number 3, there is no need to complete the form. The same individual cannot be in charge of multiple locations, and each location must have an individual in charge. The 10-year employment and residence history in the Statement of Identity and Questionnaire must be complete and accurate. Attach copies of all pertinent court and other documents requested. The Statement of Identity and Questionnaire must be notarized if executed outside the State of California. 1423-CFLL Short Form Instructions 2 American LegalNet, Inc. www.FormsWorkflow.com ITEM NUMBER 4 OF APPLICATION: Applicant’s Plan of Business: Mark the appropriate box with either a “yes” or “no” response to indicate if there has been any change in the plan of business of making or brokering loans or other business that was previously submitted to the Department of Corporations. If “yes”, explain the change. ITEM NUMBER 5 OF APPLICATION: Applicant’s License Number: Provide the existing license number and address of at least one other CFLL license currently held by the applicant. ITEM NUMBER 6 OF APPLICATION: Responsible Officer or Compliance Person: Provide the name, title, address, email address, and telephone number of the contact person to whom questions regarding the filing of this application should be directed. The responsible officer or compliance person must be from the main office of the company, and may not be a branch manager. SIGNATURE SECTION: Provide the required information. The Signature Section must be signed by an officer who has previously completed and submitted a Statement of Identity and Questionnaire to the Department of Corporations. The application must be signed by the applicant if a sole proprietor, by a general partner if a partnership, or by an authorized officer, if a corporation. 1423-CFLL Short Form Instructions 3 American LegalNet, Inc. www.FormsWorkflow.com (Department of Corporations Use Only) DEPARTMENT OF CORPORATIONS Fee Paid $ ___________________ File No. ________________________ Receipt No. __________________ STATE OF CALIFORNIA DEPARTMENT OF CORPORATIONS “SHORT FORM APPLICATION” FOR A LICENSE UNDER THE CALIFORNIA FINANCE LENDERS LAW FOR A LICENSEE CURRENTLY HOLDING ONE OR MORE LICENSES This application must be accompanied by a nonrefundable application fee of $200 and a nonrefundable investigation fee of $100. (Financial Code Section 22103.) The application (together with the fees payable to the Department of Corporations) must be filed ONLY in the Los Angeles office of the Department of Corporations, located at 320 West 4th Street, Suite 750, Los Angeles, CA 90013. A licensee seeking to engage in business at a new location must submit this application to the California Corporations Commissioner by certified mail, return receipt requested, at least 10 days before engaging in business at the new location. A license issued pursuant to the California Finance Lenders Law permits only employees to work under the license. Persons engaged in lending that are not employees may need to obtain a license under the California Finance Lenders Law. In addition, a license issued pursuant to the California Finance Lenders Law does not permit a licensee to authorize locations operated by persons other than employees of the licensee under some form of franchise or license agreement (e.g., net branching.) 1. Name of applicant: Fictitious Business Name (FBN): (FBN must already be on file with the Department. [Financial Code Section 22102(e)]) (If the applicant seeks to do business under a FBN that has not been previously approved by the Department of Corporations (Department), additional information will need to be submitted under separate cover. Use of a new proposed FBN is not allowed until such time as written approval is received from the Department approving the use of such name. Approval of a new FBN may be requested by submitting under separate cover a copy of the Fictitious Business Name Statement with the “filed stamp” from the county clerk’s office along with a written request. The applicant’s name must appear as a registrant on the Fictitious Business Name Statement. Refer to Section 17900 of the Business and Professions Code for the requirements for filing the Fictitious Business Name Statement. (Financial Code Section 22155) 1423-CFLL Short Form (Rev. 9/07) 1 American LegalNet, Inc. www.FormsWorkflow.com 2. Applicant’s licensed place of business will be located at (Financial Code Section 22106): (Number and Street) (City) (County) (Telephone Number) 3. (State) (Zip) (Fax Number) The FULL first, middle (if no middle name, so indicate) and last name of the individual in charge of this location. Each office must have a person who is in charge and the same individual cannot be in charge of multiple locations. * (Last Name) (First Name) (Middle Name) (*Complete a Statement of Identity and Questionnaire (FS 512 SIQ). The form is located on the Department of Corporations’ website at www.corp.ca.gov and is printed as Exhibit C in Section 1422. If the Statement of Identity and Questionnaire form has already been provided to the Department for this individual, there is no need to provide another form. (Financial Code Section 22105)) 4. Indicate by marking the appropriate box if there has been or will be ANY CHANGE in the applicant’s plan of business of making or brokering loans or other business as described in Financial Code Section 22154 that was previously submitted to the Department. If "yes", provide explanation. [ ] [ ] 5. Yes (explain) No Provide license number and address of one other California Finance Lenders Law license held by this applicant. License Number 6. Address Provide the name, title, address, email address, and telephone number of the person to contact regarding this application. The license will also be mailed to this person unless otherwise instructed. The name of the person must be a responsible officer or compliance person from the main office of the company. The name of the branch manager does not belong here. Attention: (Name) (Number and Street) (Title) (City) (State) (Email Address) (Zip Code) (Telephone Number) In the event of the issuance of a license, applicant agrees to comply with the requirements of the California Finance Lenders Law and rules adopted, and orders issued, by the California Corporations Commissioner, and further agrees that in the event of any change of its officers, directors, or any other persons named in this application, that an amendment to the application containing the same information in relation to the new person(s) as is required in the application shall be filed with the California 1423-CFLL Short Form (Rev. 9/07) 2 American LegalNet, Inc. www.FormsWorkflow.com Corporations Commissioner within thirty days from the date of the change. Regulations Section 1409 (10 C.C.R. § 1409).) (California Code of WHEREFORE, applicant requests that a license be issued by the California Corporations Commissioner authorizing applicant to engage in business under the California Finance Lenders Law within the State of California. If the proposed location in Item Number 2 is out-of-state, applicant agrees to make its books and records available in this state, or pay the reasonable expenses incurred during an investigation or examination outside this state. The applicant has duly caused this application to be signed on its behalf by the undersigned, thereunto duly authorized. The undersigned, on behalf of the applicant, acknowledges that this application and all exhibits thereto which are not designated as confidential are subject to public inspection pursuant to Section 250.9.1, Chapter 3, Title 10, California Code of Regulations. A request for confidentiality of certain documents may be requested pursuant to Section 250.10. If a request for confidential treatment is granted (or denied), the person making such request will be notified in writing. I declare under penalty of perjury that I have read the foregoing application, including all Exhibits attached thereto, or filed therewith, and know the contents thereof, and that the statements therein are true and correct. (Applicant) Executed at (City, County, and State) (Signature of Declarant)* Date (Typed Name of Declarant)* (Title)* *This Short Form Application must be signed by an officer who has PREVIOUSLY completed and submitted a Statement of Identity and Questionnaire. No other officer is authorized to sign documents on behalf of the applicant. 1423-CFLL Short Form (Rev. 9/07) 3 American LegalNet, Inc. www.FormsWorkflow.com NOTICE REQUIRED BY THE INFORMATION PRACTICES ACT (Cal. Civ. Code Sec. 1798.17) (a) The Department of Corporations of the State of California, Financial Services Division, requests the information solicited by the forms attached to this notice. (b) The Assistant Commissioner, Administration, 1515 K Street, Sacramento, CA 95814, telephone (916) 445-5541, shall inform individuals regarding the location of the Department's records and the categories of persons who use the information in the Department's records. (c) The Department's records are maintained pursuant to one or more of the following statutes: Financial Code Sections 12201, 12204, 12216, 12220, 17201, 17209, 17209.1, 17213.5, 22101 and 50301. (d) Except for individual Social Security Account Numbers submission of all items of information requested by the attached form is mandatory. (e) Failure to provide all or any part of the information requested by the attached form may result in the denial of the license application or other authorization sought from the Department. (f) Information supplied by individuals will be used to determine ability to conduct business consistent with the statutory requirements for the license or other authorization applied for. Information will be used as follows: (1) initial processing of an application to make necessary findings for granting or denying the license or other authority applied for; (2) assuring compliance through continuing regulatory processes including references and comparisons of the information with regard to other laws administered by the Department, various regulatory and special investigatory examination reports, and other data; and (3) undertaking enforcement proceedings seeking appropriate administrative or civil remedies or to refer matters to appropriate federal, state or local law enforcement officers. (g) In furtherance of the purposes identified above information may be transferred to other federal, state or local regulatory or law enforcement agencies. Transfers may also be made to licensees or other persons subject to the jurisdiction of the Department in order to perform statutory duties. (h) Subject to certain exceptions or exemptions, the Information Practices Act grants individuals the right to access to personal information concerning the individual which is maintained by the Department of Corporations. FS 512 SIQ (09/07) 1 American LegalNet, Inc. www.FormsWorkflow.com DEPARTMENT OF CORPORATIONS STATE OF CALIFORNIA File Number, if any Licensee (Company Name) Insert Department of Corporations file number, if any, and the name of the licensee (company) to which this Statement of Identity and Questionnaire relates. STATEMENT OF IDENTITY AND QUESTIONNAIRE Exact Full Name First Name Middle Name (Do not use initials or nicknames) Last Name Position to be filled in connection with the preparation of this questionnaire (e.g., Officer, Director, Manager, etc.). Sex Hair Eyes Birthdate See Commissioner’s Release 2-G regarding whether furnishing the social security number is mandatory or voluntary and for a description of the use made of that information. Residence Phone Number California Driver's License Number (if none, so state) Business Phone Number Email Address From Weight Birthplace Social Security Number 1. Height Hours of Employment (e.g., 8:00 a.m. to 5:00 p.m.) Residence addresses for the last 10 years: To Street City State Zip Code Present Attach separate schedule if space is not adequate. FS 512 SIQ (Rev. 9/07) 1 American LegalNet, Inc. www.FormsWorkflow.com Insert Full Name of Individual: _______________________ 2. Insert Licensee (Company Name): Employment for the last 10 years: From To Present Employer Name and Address Occupation and Duties Attach separate schedule if space is not adequate. 3. a. Have you ever been named in any order, judgment or decree of any court or any governmental agency or administrator, temporarily or permanently restraining or enjoining you from engaging in or continuing any conduct, practice or employment? Yes No If the answer is "Yes", give details: Attach a copy of any order, judgment or decree. b. Are you currently, or have you been within the last ten years, under federal, state or local investigation for possible violation of any law, ordinance, or licensing or regulatory scheme? Yes If the answer is "Yes", give details: No 4. a. Are you currently licensed to engage in financial business in this state or any other state? Yes No Financial business means securities broker-dealer or agent, investment adviser or investment adviser representative, financial planner, insurance agent, escrow agent, finance lender or broker, mortgage lender or servicer, real estate broker, payday lender, financial institution, bill payer or prorater, commodity sales person, certified public accountant, or any other business involving investment or financial transactions. If the answer is "Yes", describe in the chart next page the following for each license: FS 512 SIQ (Rev. 9/07) 2 American LegalNet, Inc. www.FormsWorkflow.com Insert Full Name of Individual: _______________________ License Period From: To: License Number Insert Licensee (Company Name): Type of License/Business Name and Address of Licensing Entity Attach separate schedule if space is not adequate. b. Have you ever been refused a license to engage in any business in this state or any other state, or has any such license ever been suspended, revoked, or surrendered subject to a settlement, or any other similar action? Yes No If the answer is "Yes", give details: Attach a copy of any settlement. 5. Have you ever been convicted of or pleaded nolo contendere to a misdemeanor or felony other than minor traffic citations that do not constitute a misdemeanor or felony offense? "Convicted" includes a verdict of guilty by judge or jury, a plea of guilty or of nolo contendere or a forfeiture of bail. All convictions must be disclosed even if the plea or verdict was thereafter set aside and the charges against you dismissed or expunged or if you have been pardoned. Convictions occurring while you were a minor must be disclosed unless the record of conviction has been sealed under Section 1203.45 of the California Penal Code or Section 781 of the California Welfare and Institution Code. Yes No If the answer is "Yes", give details: Attach a copy of any order, judgment or decree. If a conviction was entered under Section 23152(a) of the Vehicle Code, attach a written declaration stating whether drugs were involved. 6. Have you ever been a defendant in a civil court action other than divorce, condemnation or personal injury? Yes No If the answer is "Yes", please complete the following: Date of suit Location of court Nature of suit Attach a copy of any order, judgment or decree. FS 512 SIQ (Rev. 9/07) 3 American LegalNet, Inc. www.FormsWorkflow.com Insert Full Name of Individual: _______________________ 7. Insert Licensee (Company Name): Have you ever been a subject of a bankruptcy or a petition in bankruptcy? Yes No Yes No If the answer is "Yes", give date, title of case, location of bankruptcy filing: 8. Have you ever been refused a bond, or have you ever had a bond revoked or canceled? If the answer is "Yes", give details: 9. Have you ever changed your name including a woman’s maiden name or ever been known by any name other than that herein listed? Yes No If so, explain. Change in name through marriage or court order and exact date of each name change must be listed. 10. Have you ever done business under a fictitious firm name either as an individual or in any form of business, e.g. partnership, limited liability company, corporation or other? Yes No If the answer is "Yes", give details: The following questions must be answered by all persons submitting this questionnaire in connection with an ESCROW AGENT’S LICENSE. 11. In what capacity will you be employed? (e.g., Clerk, Escrow Officer, Manager, Officer, Director, etc.) 12. Do you expect to be a party to, or broker or salesman in connection with escrows conducted by the escrow company which is employing you? Yes No If the answer is "Yes", give details: FS 512 SIQ (Rev. 9/07) 4 American LegalNet, Inc. www.FormsWorkflow.com Insert Full Name of Individual: _______________________ Insert Licensee (Company Name): This statement will be considered confidential information and will be filed and maintained as part of the confidential records not subject to public inspection. VERIFICATION I, the undersigned, state that I am the person named in the foregoing Statement of Identity and Questionnaire; that I have read and signed said Statement of Identity and Questionnaire and know the contents thereof, including all exhibits attached thereto, and that the statements made therein, including any exhibits attached thereto, are true, and that I have not omitted any information needed to make this document true. This verification may be made either before a Notary Public or as a declaration under penalty of perjury. This form MUST be executed before a Notary Public if it is executed OUTSIDE the State of California. I certify/declare under penalty of perjury that the foregoing is true and correct. Executed at (City) (County) this day of (State) , 20________. (Print Name) (Signature of Individual) State of ) ) County of , 20 Date at (Signature of Individual) Subscribed and sworn to before me _________________________, 20________ ____________________________________ Notary Public in and for said County and State FS 512 SIQ (Rev. 9/07) 5 American LegalNet, Inc. www.FormsWorkflow.com STATE OF CALIFORNIA -- BUSINESS, TRANSPORTATION AND HOUSING AGENCY DEPARTMENT OF CORPORATIONS California’s Investment and Financing Authority NOTICES REQUIRED UNDER STATE AND FEDERAL LAW I. INFORMATION PRACTICES ACT OF 1977 (California Civil Code Section 1798.17) (a) The Department of Corporations of the State of California, is requesting the information specified in the application for registration, qualification, a certificate or a license. (b) The Deputy Commissioner, Office of Management and Budget, 1515 K Street, Suite 200, Sacramento, California, 95814, telephone (916) 445-5541, is responsible for the system of records and shall, upon request, inform individuals regarding the location of the Department of Corporations' records and the categories of persons who use the information in the records. (c) The records are maintained pursuant to one or more of the following laws: the Corporate Securities Law of 1968 (Corporations Code Section 25000, et seq.); the Capital Access Company Law (Corporations Code Section 28000, et seq.); the Bucket Shop Law (Corporations Code Section 29000, et seq.); the California Commodity Law of 1990 (Corporations Code Section 29500, et seq.); the Franchise Investment Law (Corporations Code Section 31000, et seq.); the Check Sellers, Bill Payers and Proraters Law (Financial Code Section 12000, et seq.); the California Deferred Deposit Transaction Law (Financial Code Section 23000, et seq.); the Escrow Law (Financial Code Section 17000, et seq.); the California Finance Lenders Law (Financial Code Section 22000, et seq.); the Securities Depository Law (Financial Code Section 30000, et seq.); and the California Residential Mortgage Lending Act (Financial Code Section 50000, et seq.). (d) The submission of all items of information is mandatory unless otherwise noted. Section 17520 of the Family Code requires the Department of Corporations to collect social security numbers from all applicants. The Privacy Act of 1974 prohibits a state agency from denying an individual any right, benefit or privilege provided by law because of the individual’s refusal to disclose the individual’s social security account number. (e) Failure to provide all or any part of the information requested may preclude the Department of Corporations from approving the application. (f) The principal purposes within the Department of Corporations for which the information is to be used are to determine whether (1) a license, qualification, registration, certificate or other authority should be accepted, granted, approved, denied, revoked or limited in any way; (2) business entities or individuals licensed or otherwise regulated by the Department of Corporations are conducting themselves in accordance with applicable laws; and/or (3) laws administered by the Department of Corporations are being or have been violated and whether OLL 001 (New 4/03) 1 American LegalNet, Inc. www.FormsWorkflow.com administrative action, civil action, or referral to appropriate federal, state or local law enforcement or regulatory agencies, or to a self-regulatory organization, as authorized by law, is appropriate. (g) Any known or foreseeable disclosures of the information pursuant to subdivision (e) or (f) of Civil Code Section 1798.24 may include transfers to other federal, state, or local law enforcement or regulatory agencies, or to a self-regulatory organization, as authorized by law. (h) Subject to certain exceptions or exemptions, the Information Practices Act grants an individual a right of access to personal information concerning the requesting individual that is maintained by the Department of Corporations. II. FEDERAL PRIVACY ACT OF 1974 (Public Law 93-579) In accordance with Section 7 of the Privacy Act of 1974 (found at 5 U.S.C. § 552a note (Disclosure of Social Security Number)), the following is information on whether the disclosure of a social security account number is voluntary or mandatory, by what statutory or other authority such number is solicited, and what uses will be made of it. (1) Section 17520 of the Family Code requires the Department of Corporations to collect social security numbers from all applicants. The Privacy Act of 1974 prohibits a state agency from denying an individual any right, benefit or privilege provided by law because of the individual’s refusal to disclose the individual’s social security account number. (2) A social security account number is solicited pursuant to one or more of the following authorities: the Corporate Securities Law of 1968 (Corporations Code Section 25000, et seq.); the Capital Access Company Law (Corporations Code Section 28000, et seq.); the Bucket Shop Law (Corporations Code Section 29000, et seq.); the California Commodity Law of 1990 (Corporations Code Section 29500, et seq.); the Franchise Investment Law (Corporations Code Section 31000, et seq.); the Check Sellers, Bill Payers and Proraters Law (Financial Code Section 12000, et seq.); the Escrow Law (Financial Code Section 17000, et seq.); the California Finance Lenders Law (Financial Code Section 22000, et seq.); the California Deferred Deposit Transaction Law (Financial Code Section 23000, et seq.); the Securities Depository Law (Financial Code Section 30000, et seq.); the California Residential Mortgage Lending Act (Financial Code Section 50000, et seq.); and the regulations adopted thereunder, as well as Section 17520 of the Family Code. (3) For all persons disclosing a social security account number, the number may be used, in addition to other information provided, to conduct a background investigation of the individual by the Department of Justice's Identification and Information Branch or by other federal, state or local law enforcement agencies, or a self-regulatory organization, as authorized by law. The social security number may also be used to respond to requests for this number made by child support agencies. OLL 001 (New 4/03) 2 American LegalNet, Inc. www.FormsWorkflow.com III. THE PERMIT REFORM ACT OF 1981 (Government Code Section 15378(b)) The Department of Corporations has established time periods for processing an application from the receipt of the initial application to the final application decision. An applicant may appeal directly to the Business, Transportation & Housing Agency for a timely resolution of any dispute arising from a violation of the time periods. Information regarding the appeal process may be found in Title 21, Chapter 6 of the California Code of Regulations, entitled Regulations Relating to Appeals Under the Permit Reform Act of 1981. OLL 001 (New 4/03) 3 American LegalNet, Inc. www.FormsWorkflow.com