HCC 90-01 i Instructions: Health Care Card Suppliers Application of Annual Notice Contact: Kansas Office of the Secretary of State Memorial Hall, 1st Floor 120 S.W. 10th Avenue Topeka, KS 66612-1594 (785) 296-4564 kssos@sos.ks.gov www.sos.ks.gov All information on the health care card suppliers form must be complete and accompanied by the correct filing fee or the document will not be accepted for filing. 1. FILING FEE: The filing fee for this document is $250. Mail completed form HCC (Health Care Card Suppliers Application of Annual Notice) along with surety bond form SB (Health Care Card Supplier Bond). 2. PAYMENT: Please enclose a check or money order payable to the Secretary of State. The health care card supplier application of annual notice received without the appropriate fee will not be accepted for filing. Please do not send cash. 3. RENEWAL DATE: The applicant must maintain a surety bond in the amount of $50,000. The surety bond Form SB shall be submitted to the Secetary of State along with the annual notice Form HCC and is subject to the approval of the Kansas Attorney General. This office will forward the bond to the Attorney General prior to filing. The month in which the supplier files its first annual notice with the Secretary of State is the month in which its filings are due annually thereafter, if the filing remains current and in compliance. 4. CANCELLATION OF BOND: No surety on a discount card company bond shall cancel such bond without giving written notice thereof to the Secretary of State and discount card company. 5. RESIDENT AGENT: The resident agent is a person who is a resident of Kansas authorized to accept service of process (lawsuits) on behalf of the applicant. This does not necessarily mean that the agent himself/herself is being sued, but that he/she has the authority and responsibility to accept service of process on behalf of the applicant. 6. REGISTERED OFFICE: The registered office is the address where the resident agent is located, which must be a numbered street address. A P.O. box is unacceptable. 7. MAILING ADDRESS: The mailing address is where you would like to receive official mail from the Secretary of State's office. 8. SIGNATURE: The health care card supplier requires the signature of any individual authorized by the card supplier. There is a $25 service fee for all checks returned by your financial institution. All information must be completed or this document will not be accepted for filing. NOTICE: Rev. 4/20/12 jdr Instructions Page 1 of 1 K.S.A. 50-1,101 American LegalNet, Inc. www.FormsWorkFlow.com HCC 90-01 CONTACT: Health Care Card Suppliers Application of Annual Notice (785) 296-4564 kssos@sos.ks.gov www.sos.ks.gov KANSAS SECRETARY OF STATE Kansas Office of the Secretary of State Memorial Hall, 1st Floor 120 S.W. 10th Avenue Topeka, KS 66612-1594 Above space is for office use only. i INSTRUCTIONS: All information must be completed or this document will not be accepted for filing. Please read instructions sheet before completing. 1. Name of the card supplier: 2. Name of the resident agent and address of the registered office in Kansas: Address must be a street address A P.O. box is unacceptable _____________________________________________________________________________________________ ________________________________________________________________________________________ Name Street Address Kansas ___________________________________________________________________________________ City State Zip 3. Mailing address: This address will be used to send official mail from the Secretary of State's office ________________________________________________________________________________________ Attention Name City Address _______________________________________________________________________________________ State Zip Country 4. I declare under penalty of perjury pursuant to the laws of the state of Kansas that the foregoing is true and correct, and I have remitted the required fee. ________________________________________________________ Signature of individual authorized by card supplier _____________________________________ Date (month, day, year) ______________________________ Phone number Rev. 4/20/12 jdr Page 1 of 1 K.S.A. 50-1,101 American LegalNet, Inc. www.FormsWorkFlow.com SB CONTACT: Health Care Card Supplier Bond KANSAS SECRETARY OF STATE Kansas Office of the Secretary of State (785) 296-4564 kssos@sos.ks.gov www.sos.ks.gov Memorial Hall, 1st Floor 120 S.W. 10th Avenue Topeka, KS 66612-1594 1. Bond Number: 2. Bond amount: ____________________________________________ ____________________________________________ ____________________________________________,of the City of _______________________, State of _____________, as Supplier/Principal, and ____________________, a business entity organized pursuant to the laws of the _______________ and authorized to issue surety bonds (Surety) are indebted to the Kansas Attorney General and other persons identified herein, in the penal sum of fifty-thousand dollars ($50,000), for which payment the Principal/Supplier and Surety bind ourselves and our successors and assigns, jointly and severally. CONDITION. The condition of this obligation is that Supplier/Principal has filed notice with the Secretary of State to sell discount cards pursuant to the Kansas Discount Card Act (Act), K.S.A. 50-1,100 et seq. and amendments thereto. Pursuant to K.S.A. 50-1,101(b), Supplier/Principal is obligated to maintain a surety bond in the amount of fifty-thousand dollars ($50,000) in favor of any person and the Kansas Attorney General for the benefit of any person who is damaged by any violation of the Act, including any violation by the Supplier/Principal or by any other person that markets, promotes, advertises or otherwise distributes a discount card on behalf of the Supplier/ Principal. If the Supplier/Principal, its agents, employees, and any other person that markets, promotes, advertises or otherwise distributes discount cards on behalf of the Supplier/Principal fails to abide by the provisions of the Act and any amendments thereto, then this obligation shall be null and void. Otherwise, the bond shall be in full force and effect. LIABILITY. Any person and the Kansas Attorney General, for the benefit of any person who is damaged by any violation of the Act, may bring an action against the Supplier/Principal for violations of the Act and make a claim against this bond. DURATION. This bond sha