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SALES FINANCE AGENCY ACT LICENSE
RENEWAL INSTRUCTIONS
Please review the following instructions prior to completing and filing:
1. Provide the correct name of licensee as it appears on
your license.
2. Provide the correct address, city, county, state and zip code
of licensee as it appears on your license.
3. Provide the telephone number of the licensed office.
4. In the event of multiple locations, the attached MULTIPLE
LOCATIONS FORM MUST be completed.
5. In all instances the INFORMATION FORM MUST be completed
and returned to our office.
6. If within the last year there have been new officer(s),
director(s), sole proprietor, owner(s), partner(s), and/or
members as so indicated on the application, the enclosed
Supplemental Application must be completed for each
individual and returned to our office with the application.
7. Include the fully completed checklist.
These renewal documents and applicable check must be received at the following address NO LATER THAN DECEMBER 1, 2004:
ILLINOIS DEPT. OF FINANCIAL & PROFESSIONAL REGULATION
DIVISION OF FINANCIAL INSTITUTIONS
CONSUMER CREDIT SECTION
100 W. RANDOLPH, SUITE 9-100
CHICAGO, IL 60601
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SPsfrenlet2.doc
THIS RENEWAL IS DUE ON OR BEFORE DECEMBER 1
SALES FINANCE AGENCY ACT
LICENSE RENEWAL CHECKLIST
ENCLOSE ALL APPLICABLE FORMS DETAILED BELOW.
_____RENEWAL APPLICATION SIGNED AND NOTARIZED
_____LICENSE #, TELEPHONE #, FAX #, CONTACT PERSON
WEBSITE ADDRESS, E-MAIL ADDRESS
_____MULTIPLE LICENSED LOCATIONS FORM
_____INFORMATION FORM
_____SUPPLEMENTAL APPLICATIONS FOR ALL NEW PRINCIPALS
_____CORRECT REMITTANCE ($300 FOR HEADQUARTERS;
$100 PER BRANCH)
IF ALL OF THE ABOVE ARE NOT INCLUDED, YOUR RENEWAL APPLICATION IS INCOMPLETE AND IT WILL BE RETURNED.
PLEASE COMPLETE THIS FORM AND RETURN WITH APPLICATION.
Prepared by:________________________
Telephone #:________________________
REsfcheck
Office Use Only
Check # _____________
Check Amt.__________
Fee Slip #____________
STATE OF ILLINOIS
DEPARTMENT OF FINANCIAL & PROFESSIONAL REGULATION
SALES FINANCE AGENCY ACT
APPLICATION FOR EXTENSION OF LICENSE
MUST BE FILED ANNUALLY ON OR BEFORE DECEMBER 1
To: Director of Financial Institutions
The undersigned hereby requests extension of LICENSE NO. ____________, heretofore issued in accordance with the provisions of the Illinois Sales Finance Agency Act.
Licensee_______________________________________________ ______________________
Corporate or Company Name Telephone No.
Contact Person:________________________ __________________ ________________
Fax No. FEIN
Website Address:______________________ E-Mail Address:_______________________
Application Prepared By: ____________________________________
Licensed Address:______________________________________________________________
Street
______________________________________________________________________________
City State Zip Code County
Give title and residence address of each new (within the last year) officer, director, sole proprietor, owner, partner or member and complete the Supplemental form for each.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Give name or names of affiliated (75% or more of stock held by same persons) corporations or firms and state character of business:____________________________________________
______________________________________________________________________________
(Application Page 1 of 2)
(Application Page 2 of 2)
We hereby tender a check, draft or money order (payable to Director of Financial Institutions) in the sum of $300.00 for headquarters office and $100.00 for each branch office as the annual license fee.
_________________________________________(Seal)
Name of Licensee
(CORPORATE SEAL) By________________________________________(Seal)
(If Corp.) (President, Owner, Partner)
By________________________________________(Seal)
(Secretary, Owner, Partner)
Subscribed and sworn to before me this _______________ day of ________________, 20___
Notary Public______________________________My Commission Expires_______________
(NOTARY SEAL)
IMPORTANT NOTICE: Disclosure of requested information is necessary to accomplish the statutory requirements. This form has been approved by the Forms Management Center.
LIsfextapl
INFORMATION FORM
I. Name, Title, Percent of Stock Ownership and Resident Address of Every Officer of the Licensed Entity.
A. _______________________________________________________________
(Name) (Title) (Percent of Stock)
_______________________________________________________________
(Address) (City) (State) (Zip Code)
B. _______________________________________________________________
(Name) (Title) (Percent of Stock)
_______________________________________________________________
(Address) (City) (State) (Zip Code)
C. _______________________________________________________________
(Name) (Title) (Percent of Stock)
_______________________________________________________________
(Address) (City) (State) (Zip Code)
(If more space is required attach a separate sheet)
II. Name, Title, Percent of Ownership and Resident Address of Each Director of the Licensed Entity.
A. _______________________________________________________________
(Name) (Title) (Percent of Stock)
_______________________________________________________________
(Address) (City) (State) (Zip Code)
B. _______________________________________________________________
(Name) (Title) (Percent of Stock)
_______________________________________________________________
(Address) (City) (State) (Zip Code)
C. _______________________________________________________________
(Name) (Title) (Percent of Stock)
_______________________________________________________________
(Address) (City) (State) (Zip Code)
(If more space is required attach a separate sheet)
(Info Form Page 1 of 2)
(Info Form Page 2 of 2)
III. Name, Percent of Ownership and Resident Address of Each Stockholder Owning 10% or More of Capital Stock or Any Owner/Partner of the Licensed Entity who is Not Listed Above.
A. _______________________________________________________________
(Name) (Percent of Stock/Ownership)
_______________________________________________________________
(Address) (City) (State) (Zip Code)
B. _______________________________________________________________
(Name) (Percent of Stock/Ownership)
_______________________________________________________________
(Address) (City) (State) (Zip Code)
C. _______________________________________________________________
(Name) (Percent of Stock/Ownership)
_______________________________________________________________
(Address) (City) (State) (Zip Code)
(If more space is required attach a separate sheet)
Lisfinf.frm
STATE OF ILLINOIS
DEPARTMENT OF FINANCIAL & PROFESSIONAL REGULATION
CONSUMER CREDIT SECTION
SALES FINANCE AGENCY ACT
SUPPLEMENTAL APPLICATION
All answers must be typed or legibly printed. All questions must be answered.
1. Individual's Name: ____________________________________________________
(First) (Middle) (Last)
2. Corporate Title: ______________________________________________________
3. Percentage of Ownership: ______________________
4. Date of Birth: ________________________________
5. Social Security Number: _______________________
6. Business Address:_____________________________________________________
7. Resident Address:_____________________________________________________
8. Telephone Number: ___________________________________________________
9. Business Experience for past ten (10) years in descending chronological order:
(A copy of a resume for the same period of time may be substituted to satisfy
this requirement.)
Years
From ________To ________ Company Name: ________________________________
Company Address: _____________________________________________________
Position Held: ________________________________________________________
Principal Duties:_________________________________________________________
(Supplemental App. Page 1 of 3)
(Supplemental App. Page 2 of 3)
Years
From ________To ________ Company Name: ________________________________
Company Address: ______________________________________________________
Position Held: ________________________________________________________
Principal Duties: _________________________________________________________
Years
From ________To ________ Company Name: ________________________________
Company Address: _______________________________________________________
Position Held: ________________________________________________________
Principal Duties: ________________________________________________________
10. In the past l0 years have you ever been convicted of a felony?
Yes No_____
If yes, provide on a separate sheet full details including a summary, the court, presiding judge(s) and the title and docket number.
11. In the past l0 years have you been a party to any material litigation?
Yes No_____
If yes, provide on a separate sheet full details including a summary, the court, presiding judge(s) and the title and document number.
(Supplemental App. Page 3 of 3)
I do hereby swear that the facts set forth, hereinabove, are true and are given as a basis for the issuance of a license under the Sales Finance Agency Act.
____________________________________
Name & Title (Please Type or Print)
____________________________________
Signature
____________________________________
Resident Address
____________________________________
City State Zip Code
Subscribed and sworn to before me this _________day of ___________, 20_____
Notary Public________________________
(NOTARY SEAL) My Commission Expires: ______________
LIsfsupapl
MULTIPLE LICENSED LOCATIONS
SALES FINANCE AGENCY ACT
Must be completed in the event of multiple licenses:
COMPANY NAME: _________________________________________________________________
DESIGNATED HEADQUARTER
LICENSE # ADDRESS COUNTY PHONE # AMOUNT
_____ ______ _______ _____ $ 300.00
BRANCH OFFICE(S) (100.00 EACH LICENSE)
LICENSE # ADDRESS COUNTY PHONE # AMOUNT
_____ _______ _______ ____ _ ___
_____ _______ _______ ____ _ ___
_____ _______ _______ ____ _ ___
_____ _______ _______ ____ _ ___
_____ _______ _______ ____ _ ___
_____ _______ _______ ____ _ ___
_____ _______ _______ ____ _ ___
TOTAL AMOUNT $ _
................
................
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