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2393950-61595000STATE OF NEW MEXICOREGULATION AND LICENSING DEPARTMENTFINANCIAL INSTITUTIONS DIVISION2550 Cerrillos Road, 3rd Floor, Santa Fe, NM 87505P.O. Box 25101, Santa Fe, NM 87505-5101Phone: (505)476-4908Fax: (505)476-4670rld.state.nm.us/financialinstitutionsLicensing Specialist: Jackie.Dalmy@state.nm.us-31750140970RENEWAL APPLICATION FOR MOTOR VEHICLE SALES FINANCE LICENSE0RENEWAL APPLICATION FOR MOTOR VEHICLE SALES FINANCE LICENSEGENERAL INSTRUCTIONSUse this form if you are applying to renew a Motor Vehicle Sales Finance license. If you do not currently maintain a Motor Vehicle Sales Finance license, do not use this form. Instead, complete the Application for Original Motor Vehicle Sales Finance License, available on the financial institutions division website.The enclosed renewal application must be completed in its entirety. Renewal applications containing incomplete responses, or lacking renewal fees or exhibits will be returned to the applicant. Please complete the checklist on the last page of this packet to ensure that your renewal application is complete.3. In the event space provided for answers is inadequate, additional pages should be attached, however, attachments must identify the following information in the top right corner of every page: applicant name and the specific item on the application to which the answer relates.4. All exhibits must include the following information in the top corner of every page: applicant name and exhibit letter. 5. The license renewal fee for a principal business location located in state, or a branch located in state is four hundred dollars ($400.00). The license renewal fee for a principal business location or a branch located out of state is five hundred dollars ($500.00). The only acceptable methods of payment are checks or money orders payable to the Financial Institutions Division.6. If you maintain more than one location, each location must be licensed. Therefore, each location or branch must complete a renewal application if already licensed, and each location must pay a renewal fee. 7. All renewed licenses for Motor Vehicle Sales Finance will expire at the close of business on December 31st of each year, unless renewed for the upcoming year.8. The renewal fee must be mailed to: The Financial Institutions Division, 2550 Cerrillos Road, 3rd Floor Santa Fe, NM 87505.9. The notarized renewal application, exhibits, and attachments can be scanned and emailed to Jackie Dalmy at Jackie.Dalmy@state.nm.us or mailed to the address listed above, along with your renewal fee.-88900-222250GENERAL APPLICANT INFORMATION0GENERAL APPLICANT INFORMATION1Name of Applicant: FORMTEXT ?(The person or legal entity applying for this license)2D/B/A if applicable: FORMTEXT ?(“Doing Business As”)(Fictitious Name)3Type of Business Organization:? New Mexico Corporation ? Foreign Corporation ? Limited Liability Company (LLC)? Partnership ? Sole Proprietor ? Limited Liability Partnership (LLP)4Applicant’s website and email where all official correspondence may be sent: FORMTEXT ?(website) FORMTEXT ? (Email)- This field must be completed to receive official correspondence5Physical address for the business location FORMTEXT ?that maintains this(Street Address)license: FORMTEXT ?(City) (State) (Zip Code)6Current License Number: FORMTEXT ?7Are there any other Motor Vehicle Sales Finance branches or locations affiliated with the applicant?? Yes- List name and address of all other affiliated branches or locations below. ? NoNote each location or branch must submit a renewal application and renewal fee if already licensed. If the additional location(s) or branch(es) is not yet licensed, youmust submit an original application for license for that location/branch. 8Name and Address of any affiliated FORMTEXT ?branches, locations,(Name) (Is this a branch, other location, or parent company?)or parent company: FORMTEXT ?(Street Address) FORMTEXT ?(City) (State) (Zip Code)9Applicant’s Registered Agent: FORMTEXT ?(must be a resident of(Name of Registered Agent) (Phone)New Mexico) FORMTEXT ?(Street Address) FORMTEXT ?(City) (State) (Zip Code) FORMTEXT ?(Email)- This field must be completed to receive official correspondence10Name and phone number of manager at physical address: FORMTEXT ?(Name) (Phone)Question 11: List the name, address, title, and ownership percentage interest of each director, senior officer, member, trustee or partner. NAMEADDRESSTITLEOWNERSHIP PERCENTAGE FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ? FORMTEXT ???? ?Question 12: State Reference: Enter appropriate number in the box for each jurisdiction where the applicant has applied for a Motor Vehicle Sales Finance license, became licensed in motor vehicle sales financing, or terminated a Motor Vehicle Sales Finance license within the past year.Enter 1 if applicant has a pending application in that jurisdictionEnter 2 if applicant became licensed in that jurisdictionEnter 3 if applicant is no longer licensed in that jurisdictionAL FORMTEXT ?????FL FORMTEXT ?????LA FORMTEXT ?????NE FORMTEXT ?????OK FORMTEXT ?????VT FORMTEXT ?????AK FORMTEXT ?????GA FORMTEXT ?????ME FORMTEXT ?????NV FORMTEXT ?????OR FORMTEXT ?????VA FORMTEXT ?????AZ FORMTEXT ?????HI FORMTEXT ?????MD FORMTEXT ?????NH FORMTEXT ?????PA FORMTEXT ?????WA FORMTEXT ?????AR FORMTEXT ?????ID FORMTEXT ?????MA FORMTEXT ?????NJ FORMTEXT ?????RI FORMTEXT ?????WV FORMTEXT ?????CA FORMTEXT ?????IL FORMTEXT ?????MI FORMTEXT ?????NM FORMTEXT ?????SC FORMTEXT ?????WI FORMTEXT ?????CO FORMTEXT ?????IN FORMTEXT ?????MN FORMTEXT ?????NY FORMTEXT ?????SD FORMTEXT ?????WY FORMTEXT ?????CT FORMTEXT ?????IA FORMTEXT ?????MS FORMTEXT ?????NC FORMTEXT ?????TN FORMTEXT ?????DE FORMTEXT ?????KS FORMTEXT ?????MO FORMTEXT ?????ND FORMTEXT ?????TX FORMTEXT ?????DC FORMTEXT ?????KY FORMTEXT ?????MT FORMTEXT ?????OH FORMTEXT ?????UT FORMTEXT ?????4445011430I. REGULATORY DISCLOSURE00I. REGULATORY DISCLOSUREWithin the past year, has the applicant, or any parent company, or any partner, member, officer, director, trustee, principal employee or shareholder owning ten percent (10%) or more of outstanding stock of the applicant:Applied for any other type of business license with this Division? Yes ? No ?Been refused any type of business license by a state or federal Yes ? No ? financial institutions regulating agency?Been the subject of enforcement actions such as cease and Yes ? No ?desist orders, consent orders, injunctions, and license suspensions or revocations by any state or federal regulatory agency?133350179070REGULATORY DISCLOSURE EXHIBITS00REGULATORY DISCLOSURE EXHIBITS? EXHIBIT A: BUSINESS LICENSING INFORMATIONIf you answered YES to question 13, please attach complete details of all applications submitted to this Division, including the following information:The name of the business listed on the application;The type of business license applied for;A statement indicating whether the license was granted or denied; ? EXHIBIT B: REGULATORY ENFORCEMENT ACTION HISTORYIf you answered YES to question 14 or 15, please attach complete details of all events or proceedings, including the following information: The name of the regulating agency that executed the enforcement action;The contact information for the regulating agency that executed the enforcement action; A copy of the enforcement action filed by the regulating agency;Any other relevant information.44450-156210II. CIVIL DISCLOSURE00II. CIVIL DISCLOSUREWithin the past year, has the applicant, or any parent company, or any partner, member, officer, director, trustee, principal employee or shareholder owning ten percent (10%) or more of outstanding stock of the applicant:Been the subject of proceedings in bankruptcy, foreclosure, receivership, assignment for the benefit of creditors, or for debt and money due?Been the subject of consumer initiated litigation or arbitration filed in connection with a financial services-related business?Been the subject of any litigation that, according to generally accepted accounting principles, is deemed significant to financial health and would be required to be referenced in an annual audited financial statement, report to shareholders, or similar documents?44450151765CIVIL DISCLOSURE EXHIBITS00CIVIL DISCLOSURE EXHIBITSYes ? No ?Yes ? No ?Yes ? No ? ? EXHIBIT C: CIVIL LITIGATION If you answered YES to any of the above, please attach complete details of all events or proceedings, including the following information: A copy of the original filed complaint;A description of the action, including a statement indicating whether the action is still pending;If the action has been resolved, provide a copy of the document evidencing final disposition of the case. Ex: Settlement AgreementAny other relevant information.-5080017780III. CRIMINAL DISCLOSURE00III. CRIMINAL DISCLOSUREWithin the past year, has the applicant, or any partner, member, officer, director, trustee, principal employee or shareholder owning ten percent (10%) or more of outstanding stock of the applicant:Pled guilty or nolo contendere “no contest” in a domestic, Yes ? No ?foreign, or military court to any felony?Been convicted in a domestic, foreign, or military court Yes ? No ?of any felony?Had pending charges for any felony?Yes ? No ?Pled guilty or nolo contendere “no contest” in a domestic, Yes ? No ?foreign, or military court to committing, or conspiring to commit, or attempting to commit a crime which resulted in a misdemeanor conviction involving: (1) any aspect of the motor vehicle sales finance business (2) fraud (3) theft or larceny (4) issuing worthless checks (5) forgery?Had pending charges for any misdemeanor involving committing,Yes ? No ?conspiring, or attempting to commit a crime involving (1) any aspect of the motor vehicle sales finance business, (2) fraud (3) theft or larceny (4) issuing worthless checks (5) forgery?-5080081915CRIMINAL DISCLOSURE EXHIBITS00CRIMINAL DISCLOSURE EXHIBITS? EXHIBIT D: PENDING CRIMINAL LITIGATIONIf you answered YES to questions 21 or 23 above, please attach complete details of all events or proceedings, including the following information: The defendant’s name;The city, county, and state in which the defendant was charged;The name of the Court where official records can be found;The applicable court case number;A list of the charges;Any other relevant information.? EXHIBIT E: PRIOR CRIMINAL LITIGATIONIf you answered YES to questions 19, 20, or 22, please attach copies of the court documents which evidence a final disposition of the case. Examples of these documents include a Judgment and Sentence, Final Order, Nolle Prosequi, or an Order of Conditional Discharge.63500-69850FINANCIAL DISCLOSURE00FINANCIAL DISCLOSURE 1270081915Applicant must complete all fields below. If the answer is “none,” “not applicable,” or “unknown” indicate as such on the form. Fields that are left blank will cause the Division to return the renewal application to the applicant as incomplete. If the space on this form is inadequate, attach a separate schedule that is signed and dated by the preparer. Once you have completed the fields in the table below, please print this page and affix original signature to the attestation at the bottom of the page.00Applicant must complete all fields below. If the answer is “none,” “not applicable,” or “unknown” indicate as such on the form. Fields that are left blank will cause the Division to return the renewal application to the applicant as incomplete. If the space on this form is inadequate, attach a separate schedule that is signed and dated by the preparer. Once you have completed the fields in the table below, please print this page and affix original signature to the attestation at the bottom of the page.ASSETSCash on hand and in Banks FORMTEXT ???? ?Notes, Loans, and Other Receivables Considered Good and Collectible FORMTEXT ???? ? FORMTEXT ???? ?Marketable Securities FORMTEXT ???? ?Real Estate FORMTEXT ???? ?Business Interests FORMTEXT ???? ?IRAs or Other Retirement Accounts FORMTEXT ???? ?Life Insurance (face amount $ FORMTEXT ?)Cash Surrender Value FORMTEXT ???? ? FORMTEXT ???? ?Other Assets FORMTEXT ???? ? TOTAL ASSETS FORMTEXT ???? ?LIABILITIESNotes Payable to Banks FORMTEXT ???? ?Other Notes Payable FORMTEXT ???? ?Real Estate Mortgages FORMTEXT ???? ?Interest and Taxes Due and Unpaid FORMTEXT ???? ?Other Debts and Liabilities FORMTEXT ???? ? TOTAL LIABILITIES FORMTEXT ???? ? NET WORTH FORMTEXT ???? ?TOTAL LIABILITIES AND NET WORTH FORMTEXT ???? ?STATEMENT OF INCOMEINCOME ITEMCURRENT YEARSalaries, wages and commissions from employment FORMTEXT ???? ?Income from dividends and interest FORMTEXT ???? ?Net Income from rents, royalties and investments FORMTEXT ???? ?Other income FORMTEXT ???? ?TOTAL INCOME FORMTEXT ???? ?Taxes (federal and state income taxes) FORMTEXT ???? ?NET INCOME (after taxes) FORMTEXT ???? ?I, _________________________________________________________________________________(Applicant Name) (Business Address)hereby certify that the financial disclosure information submitted to the State of New Mexico Financial Institutions Division is a correct and complete statement of financial condition as of the date signed herein.___________________________________ _____________________(Applicant Signature)(Date) 12700-428625APPLICANT’S OATH AND STATEMENT0APPLICANT’S OATH AND STATEMENTSTATE OF_______________________))COUNTY OF_____________________ )I, _________________________________, the undersigned, being the ___________________________ (printed name of authorized representative) (Officer [title], partner or owner)of ________________________________________________________ understand that application is (name of applicant company)hereby made for a renewed Motor Vehicle Sales Finance License as provided for in Chapter 58-19-1 et seq., New Mexico Statutes, to engage in business at the location herein specified. I hereby affirm under penalties of perjury, that all information, statements, attachments, and exhibits submitted with this application are true and correct and to the best of my knowledge. I acknowledge that any misstatements contained herein may cause the Financial Institutions Division to deny the renewal application for license, or to initiate later proceedings against this license. I understand that a license, if granted, is a revocable privilege to be enjoyed and exercised only in accordance with all the terms and conditions of the Motor Vehicle Sales Finance Act and the lawful regulations of the Director promulgated under, and accompanying, the Act. ________________________________ (Signature of Authorized Representative) EXECUTED THIS ________________day of _________________, 20______. SUBSCRIBED AND SWORN TO before me on this _____ day of ______________, ______ by _______________________________________ in ___________________________, _______________.(name of person making statement) (City) (State)________________________________(Notary Public)My commission expires:(Notary seal) ________________________________-31750285750APPLICATION CHECKLIST0APPLICATION CHECKLISTBefore submitting your application to the Financial Institutions Division, please ensure that the following items are included in your submission packet:? All attachments include applicant name and question number in the top right corner of each page.? All exhibits include the applicant name and the exhibit letter in the top right corner of each page.MANDATORY EXHIBITS AND FORMS:? APPLICANT’S NOTARIZED OATH AND STATEMENT ? FINANCIAL DISCLOSURE FORM SIGNED AND DATED BY PREPARER? CHECK OR MONEY ORDER PAYABLE TO FINANCIAL INSTITUTIONS DIVISON FOR RENEWAL FEEMANDATORY EXHIBTS IF APPLICABLE:? EXHIBIT A: BUSINESS LICENSING INFORMATION? EXHIBIT B: REGULATORY ENFORCEMENT ACTION HISTORY? EXHIBIT C: CIVIL LITIGATION ? EXHIBIT D: PENDING CRIMINAL LITIGATION? EXHIBIT E: PRIOR CRIMINAL LITIGATION ................
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