PCSC 001 (Rev. 10/2018) Secretary of State OFFICE OF SECRETARY OF STATE CORPOR A TIONS DIVISION 313 West Tower 2 Martin Luther King Jr. Dr. Atlanta, GA 30334 (404) 656 - 2817 sos.georgia.gov/corporations APPLICATION FOR REGISTRATION OF PRIVATE CHILD SUPPORT COLLECTOR Personally appeared be f ore m e the undersigned being duly sworn accor d ing to law, and swears to the facts contained in this notice. Pursuant to O.C.G.A. 247 247 10 - 1 - 393.9 and 10 - 1 - 393.10 as a m ended, the unders i gned hereby applies to register with the Office of Secretary of State as a private child support collector in the State of Georgia . 1. The na m e of the applicant is: 2. The office address of the applicant is: 3 . The contact information for the applicant is as follows: Name: Title: Telephone Number : Fax Number: Email Address: 4. The registered agent for the applicant is: Name: Address (must be a physical address; P.O. boxes are not acceptable) : Telephone Number : Email Address: 5. Is the applicant registered with the Georgia Secretary of State as a domestic corporation, limited liability company, or limited partnership, or a registered foreign entity with a valid Certificate of Authority ? Yes No American LegalNet, Inc. www.FormsWorkFlow.com PCSC 001 (Rev. 10/2018) 6. Surety Bond Information: Has applicant secured a surety bond in the amount of no less than $50,000.00 ? Yes No If yes, you must provide surety bond documentation with this application. Pursuant to O.C.G.A. 10 - 1 - 393.9, the surety bond must be issued by a surety authorized to do business in this state ; t he surety bond must be issued in favor of the state for the benefit of a person damaged by a violation of O.C.G.A. 247 10 - 1 - 393.9 ; and the s urety b ond must be conditioned pliance with O.C.G.A. 247247 10 - 1 - 393.9 and 10 - 1 - 393.10 and the faithful performance of its obli gations under the private child support , or money order made pay able to the Secretary of State with this application. 7. By submitting this application, the applicant agrees to comply will all applicable state laws and regulations, with O.C.G.A. 247247 10 - 1 - 3 9 3 .9 and 10 - 1 - 3 9 3. 10 , and faithfu l l y perform the obligations u Submit ted this day of , 20 . Signature Print Name Title State of County of Sworn to and subscribed before m e this day of , 20. Notary Public Signature My Com m ission expires: American LegalNet, Inc. www.FormsWorkFlow.com