APPLICATION FOR COLLECTION AGENCY LICENSE CONNIE LAWSON INDIANA SECRETARY OF STATE SECURITIES DIVISION 302 W. Washington Street, Rm. E111 Indianapolis, IN 46204 Telephone: (317) 232-6681 www.sos.IN.gov Main office filing fee: $100.00 State Form 40495 (R7 / 4-12) Branch office filing fee: $30.00 Approved by State Board of Accounts, 2011 Filing fees should be made payable to “Secretary of State”. Indiana Code 25-11-1 et seq. INFORMATION AND INSTRUCTIONS 1. 2. 3. 4. 5. 6. 7. 8. 9. Please read this application carefully. The application must be legible. To ensure continuous operation of a collection agency, please return the completed renewal application by the 1st of December of each renewal year. Each out-of-state agency must include with this application a valid Collection Agency License from the Issuing home state or a statement your home state does not require a license. A check made payable to the Indiana Secretary of State must accompany the application. Cash will not be accepted. The application fee is $100.00 plus an additional $30.00 with each branch office application. Registration must be renewed every two (2) years. The applicant must obtain a bond from a surety company authorized to do business in Indiana. The bond must be filed with this application. Each office wishing to collect in Indiana must provide a Collection Agency Application and a $5000.00 bond. If the applicant is a Partnership or a L.L.P. (Limited Liability Partnership), please include with this application the name of each partner and the residential address of at least one partner. If the applicant is a L.L.C. (Limited Liability Company), please include with this application the date and place of organization of the L.L.C., the names of each manager and member of the L.L.C., and the residential address of at least one manager of the L.L.C. If the applicant is a Corporation, please include with this application the date and place of incorporation, the names of all officers of the corporation, and the residential address of at least one of the officers of the corporation. Type of application (check one) Original Application Type of office (check one) Renewal application Main office Branch office Type of company (check one) Individual Partnership Limited Liability Partnership (L.L.P.) Limited Liability Company (L.L.C.) Corporation Name of company or, if the applicant is an individual, name of individual County Business address (number and street, city, state, and ZIP code) Doing business as, if applicable Fax number ( Telephone number (including any 800 number) ) ( ) Name of principal Home address (number and street, city, state, and ZIP code) E-mail address Telephone number ( ) Name of person to whom correspondence may be addressed if different from principal Business address (number and street, city, state, and ZIP code) E-mail address Telephone number ( ) List any offices to be located in Indiana. Address (number and street, city, state, and ZIP code) County Address (number and street, city, state, and ZIP code) County Address (number and street, city, state, and ZIP code) County Address (number and street, city, state, and ZIP code) County Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Is applicant a resident of the State of Indiana? Yes No (If not, applicant must appoint a resident agent for service of process and agree that service upon such agent will be valid service upon the applicant. The statement appointing the agent must accompany this application and must include the address and telephone number of the agent.) Is the applicant a judge or law enforcement officer? Yes No Has any member, partner or officer of this business been convicted of a misdemeanor or felony within the past ten (10) years? Yes No Is any member, partner, or officer of this business a law enforcement officer or judge? Yes No AFFIDAVIT I, ______________________________________________, as principal of the foregoing business entity, do solemnly swear that: (1) every partner, member, manager, or officer of this collection agency business, including myself, is: (a) a citizen of the United States of America; (b) of good moral character; (c) not less than eighteen (18) years of age; (d) not a person who has ever defaulted in the payment of money collected or received for another: (e) not a former licensee in this state whose license has been suspended or revoked and not subsequently reinstated. I further swear and affirm that the foregoing answers and statements in this application and any related forms were made by me and that they are true and accurate to the best of my knowledge and belief. NOTARY CERTIFICATE STATE OF ____________________________________ COUNTY OF __________________________________ } SS: I, ____________________________________________ (principal), having been duly sworn, say that I am the above-named principal and that the application is true to the best of my knowledge and belief. Signature of applicant Printed or typed name of applicant Signature of Notary Public Printed or typed name of Notary Public Date signed and witnessed by Notary Public (month, day, year) County of residence Page 2 of 2 Date commission expires (month, day, year) American LegalNet, Inc. www.FormsWorkFlow.com