Free HCC.pmd - Kansas

Contact Information
Kansas Secretary of State Ron Thornburgh Memorial Hall, 1st Floor 120 S.W. 10th Avenue Topeka, KS 66612-1594 (785) 296-4564 [email protected] www.kssos.org

KANSAS SECRETARY OF STATE

Health Care Card Suppliers
All information must be completed or this document will not be accepted for filing.

HCC
90-01

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1. Name of card supplier:

Please complete the form, print, sign and mail to the Kansas Secretary of State with the filing fee. Selecting 'Print' will print the form and 'Reset' will clear the entire form.

2. Address:
Do not write in this space

3. Phone number: 4. Kansas law requires a discount health care card supplier to: A. maintain a surety bond in the amount of $50,000 issued by a surety company authorized to do business in Kansas (applicant may use the Kansas Secretary of State's form SB - Bond for Health Care Card Supplier), or B. maintain a surety account in the amount of $50,000 at a federally insured bank, savings and loan association or federal savings bank located in the state of Kansas. A copy of the bond or a statement identifying the surety account must be attached. The statement for a surety account must identify the depository, trustee and account number of the surety account. The bond or surety account must comply with K.S.A. 50-1,101(b)(6). 5. Kansas law requires a discount health care card supplier, both sellers and distributors, to maintain a Kansas resident agent for service of process pursuant to K.S.A. 60-306. Foreign discount health care card suppliers who are not required to register with the Kansas Secretary of State's office should use form ASA - Appointment of Service Agent for Discount Card Supplier. 6. The applicant must provide proof annually of the bond's renewal or the continuance of the surety account accompanied by this form and the required filing fee on or before the anniversary date of the applicant's initial filing. Instructions 1. Please submit this form with a $250 filing fee. 2. This form must be accompanied by a copy of the surety bond, or if a surety account is used, a statement identifying the depository, trustee and account number of the surety account. 3. This form must be filed annually to comply with Kansas law. Notice: There is a $25 service fee for all returned checks.
Rev. 05/13/09 jls

Contact Information
Kansas Secretary of State Ron Thornburgh Memorial Hall, 1st Floor 120 S.W. 10th Avenue Topeka, KS 66612-1594 (785) 296-4564 [email protected] www.kssos.org

KANSAS SECRETARY OF STATE

Health Care Card Supplier Bond
All information must be completed or this document will not be accepted for filing.

SB
90-01

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Reset

Bond number: Bond amount: KNOWALL PERSONS BYTHESE PRESENTS, that we,

Please complete the form, print, sign and mail to the Kansas Secretary of State with the filing fee. Selecting 'Print' will print the form and 'Reset' will clear the entire form.

Do not write in this space
Name of applicant

, county of , state of , as , a corporation duly organized and existing under the laws of the state of , and authorized to do business in the state of Kansas, as SURETY, are held and firmly bound unto the Attorney General of Kansas, in the penal sum of $50,000 lawful money of the United States for the payment of which sum, well and truly to be made, we bind ourselves, our heirs, executors, administrators, successors, and assigns, jointly and severally, firmly by these presents. The condition of this obligation is such that: Whereas, Discount Card Act, K.S.A. 50-1,100 et. seq. (the Act); , APPLICANT, is subject to the provisions of the Kansas Health

of the city of APPLICANT, and

NOW , THEREFORE, if the above bonded Applicant shall faithfully comply with the provisions of the Act, as amended, and the orders legally made pursuant thereto, then and in that event the foregoing obligation shall be void, otherwise to remain in full force and effect. PROVIDED, HOWEVER, AND UPON THE FOLLOWING EXPRESS CONDITIONS: That any person or the Kansas Attorney General claiming against the bond or SURETY ACCOUNT for a violation of the Act occurring during the time period during which this bond is in effect may maintain an action at law against the APPLICANT and against the SURETY or TRUSTEE of the SURETYACCOUNT. The aggregate liability of the SURETY or TRUSTEE of the SURETYACCOUNT to all persons damaged by violations of the Act may not exceed the amount of the surety bond. FURTHER, this bond is executed by the SURETY upon the express condition that the said SURETY, may, if it shall so elect, cancel said bond by giving notice in writing to the Kansas Secretary of State's office, and the said bond shall be deemed cancelled at the end of sixty (60) days. In the case of such cancellation by the SURETY, no further obligation shall be incurred under this bond after the expiration of said sixty (60) days, but the liability of the APPLICANT and SURETY shall apply as above set out as to any acts or omissions which may have occurred prior to the effective date of such cancellation.

Page 1 of 2

The effective date of the bond is
Month Day Year

and shall remain effective for one year from

the filing date of the registration. Signed and sealed this day of , 20 .

Principal name

Title

Signature

Surety name

Title

Signature

WITNESS/ATTEST

Signature

Signature

Instructions 1. Please submit with Kansas Secretary of State form HCC - Health Care Card Suppliers. 2. The filing fee for form HCC includes the form SB - Health Care Card Supplier Bond.
Notice: There is a $25 service fee for all returned checks.


Rev. 05/13/09 jls

K.S.A. 50-1,101 Page 2 of 2