CONNIE LAWSON SECRETARY OF STATE SECURITIES DIVISION 302 W. Washington Street, Room E111 Indianapolis, Indiana 46204 Telephone: (317) 232-6681 www.sos.in.gov COLLECTION AGENCY BOND State Form 873 (R4 / 4-12) Bond number VALIDATION DATE KNOW ALL MEN BY THESE PRESENTS: From: That we, ___________________________________, of______________________________ (Name of Collection Agency Business) (City) Surety telephone number ( ) in the state of ______________________________ , and _____________________________ a corporation organized and existing (Name of Surety) under and by virtue of the laws of the State of______________, and duly authorized to transact the business of indemnity and suretyship in the State of Indiana, for the use and benefit of all persons damaged by the breach of any of the conditions of this obligation, in the sum of FIVE THOUSAND DOLLARS ($5,000.00), lawful money of the United States for the payment of which sum, will and truly to be made, we bind ourselves, our heirs executors, administrators, successors and assigns, jointly and severally, firmly by these presents. THE CONDITIONS OF THE ABOVE OBLIGATION ARE SUCH THAT: WHEREAS, the above bounden Collection Agency has made application to the Securities Commissioner of the State of Indiana for license as a collection agency under the provision of IC 25-11-1 and is required by the provisions of said Law to furnish a surety bond in the sum above named, conditioned as herein set forth. NOW, THEREFORE, if the said Collection Agency shall faithfully comply with the provisions of IC 25-11-1 and shall pay to any person entitled thereto all damages as may be caused to such person by the failure of the Collection Agency to faithfully comply with the provisions of said Act; and if said Collection Agency shall pay to any person entitled thereto all damages as may be caused to any person together with all penalties provided by IC 25-11-1-3(c), then this obligation shall be void; otherwise it shall remain in full force and effect. This bond is subject to the following provisions: 1. Any person who sustains such damages as covered by this bond may bring an action upon this bond; provided, however, that the aggregate liability of the said Surety to all such persons shall, in no event, exceed the amount of the bond. 2. This bond shall be and remain in full force and effect indefinitely, subject however, to cancellation by the said Surety giving written notice both to the said Collection Agency and the Securities Commissioner of Indiana thirty (30) days prior to the effective date thereof, of its intention to terminate its liability under this bond or until the license of said Collection Agency as such loan broker is terminated either by expiration without renewal or by revocation for any cause. 3. Every person who has a cause of action under IC 25-11-1 may bring action upon this bond to enforce any liability on the bond providing, however, that no suit on this bond may be maintained to enforce any liability on this bond unless brought within two (2) years after the act upon which it is based. IN WITNESS WHEREOF, the parties hereto have set their hand and seals this __________________________ day of____________________________, ________. Surety By: Collection Agency By: _______________________________________ _______________________________________ Its: Its: _______________________________________ _______________________________________ (Title) (Title) American LegalNet, Inc. www.FormsWorkFlow.com