FIS 0513 (04/11) Office of Financial and Insurance Regulation Debt Management Act Affidavit of Character PLEASE NOTE: Submit three Affidavit of Character forms, along with a Business History Form, and a Fingerprint Card (available through OFIS by calling 1-877-999-6442) for each officer, director, partner, proprietor, member counselor, and office manager. (Note: This form is not required to be completed by a director or its equivalent, if he/she does not receive a salary, stock dividend, or other financial benefit from the corporation or equivalent entity, other than reimbursement of the actual expenses incurred in carrying out the duties of a director of that corporation or equivalent entity.) Make copies as needed Applicant Debt Management Firm Date of Submission , after being first sworn, deposes and says: That I am personally acquainted with the applicant, . I have known the applicant for a period of at least two (2) years and that applicant is of good moral character and that the reputation of the applicant for honesty and integrity is good. Signature of Affiant Date Address State of ________________________________ County of _____________________________ Subscribed and sworn to before me this __________ day of _____________________________ County of ______________________, State of __________________________ Notary Public My Commission Expires 1975 PA 148 as amended required submission of this form by applicants for a license to do business as a Debt Management company. Failure to complete and submit this form properly could result in denial, suspension or revocation of your license. American LegalNet, Inc. www.FormsWorkFlow.com