Free 40495.FH11 - Indiana

Reset Form

APPLICATION FOR COLLECTION AGENCY LICENSE
State Form 40495 (R4 / 7-06) Indiana Code 25-11-1 et seq. Approved by State Board of Accounts, 2006

Original application filing fee: $100.00 Renewal application filing fee: $100.00 Branch office filing fee: $30.00 Filing fees should be made payable to Secretary of State.

INDIANA SECRETARY OF STATE SECURITIES DIVISION 302 W. Washington Street, Rm. E111 Indianapolis, IN 46204 Telephone (317) 232-6681 www.sos.IN.gov

Please check one:

Original Application

Renewal application INFORMATION AND INSTRUCTIONS

Branch office

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 its application a valid license from the issuing home state. A check made payable to the Secretary of State must accompany the application. Cash will not be accepted. The application fee is $100.00 plus an additional fee of $30.00 for each branch office operated in Indiana. Registration must be renewed every two (2) years. 6 . 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 and Indiana based branch office must provide a $5,000.00 bond.
(Check one)

1. 2. 3. 4. 5.

INDIVIDUAL

PARTNERSHIP

LIMITED LIABILITY PARTNERSHIP (L.L.P.)

LIMITED LIABILITY COMPANY (L.L.C.)

CORPORATION

Name of applicant Business address (number and street) City Name under which business is conducted, if different State Fax number ZIP code County Telephone number (including any 800 number)

(

)

(

)

Name of principal to whom correspondence may be addressed Address (number and street, city, state, and ZIP code) Telephone number

(
Social Security number * Date of birth (month, day, year) Place of birth

)

* Your Social Security number is being requested by this state agency. Your disclosure is voluntary. This application will not be refused if you do not disclose your SSN.

Principal's home address (and prior address if less than two years at present address)

State the address of each branch office to be maintained in Indiana ADDRESS (number and street, city, state, and ZIP code) ADDRESS (number and street, city, state, and ZIP code) ADDRESS (number and street, city, state, and ZIP code) ADDRESS (number and street, city, state, and ZIP code) County County County County

Yes No Is applicant a resident of the State of Indiana? (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?
Effective date (month, day, year)

Yes

No

FOR STAFF USE ONLY
Registration number

(see reverse side)

ADDITIONAL INSTRUCTIONS 7. 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. 8. 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. 9. 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.

AFFIDAVIT I, ________________________, as applicant and 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 I,

}

SS:

, having been duly sworn, say that I am the

above-named applicant, that I have personally prepared the foregoing application, and that the same is true to the best of my knowledge and belief.

Signature of applicant

Signature of Notary Public

Printed or typed name of applicant

Printed or typed name of Notary Public

Date subscribed and sworn to Notary Public (month, day, year)

County of residence

Date commission expires (month, day, year)