Declaration of Activity



[pic]

STATE OF WASHINGTON

DEPARTMENT OF FINANCIAL INSTITUTIONS

division of Consumer Services

P.O. Box 41200 ( Olympia, Washington 98504-1200

Telephone (360) 902-8703 ( TDD (360) 664-8126 ( FAX (360) 664-2258 (

Tax refund anticipation loan facilitators’

registration form

Instructions

1. Complete the form below (page 2).

2. Write a check payable to the “Washington State Treasurer” for $35.00 per EFIN. (For example, your main office has a unique EFIN. Three of your branch offices each have unique EFINs. Your website address has a unique EFIN.  You have a total of five EFINs. Your registration fee is $35.00 x 5 = $175.00.)

3. Mail the completed form and your registration fee to:

Department of Financial Institutions

P.O. BOX 41200

Olympia, WA 98504-1200

Additional Offices

For additional offices, please use this form as many times as needed.

Questions? Contact Us.

|Phone |(360) 902-8703 |

|Toll-Free |1-877 RING DFI (746-4334) |

|Email |dcs@dfi. |

|Fax |(360) 664-2258 |

| | |

| | |

[pic]

STATE OF WASHINGTON

DEPARTMENT OF FINANCIAL INSTITUTIONS

division of Consumer Services

P.O. Box 41200 ( Olympia, Washington 98504-1200

Telephone (360) 902-8703 ( TDD (360) 664-8126 ( FAX (360) 664-2258 (

Tax refund anticipation loan facilitators’

registration form

|Company Name |      |

|Trade Name |      |

|Contact Person |      |

|Physical Address |      |

| City |

|      |

|State |

|      |

|Zip |

|      |

| |

|Mailing Address |      |

| City |

|      |

|State |

|      |

|Zip |

|      |

| |

|Company Phone |(   ) |

| |    - |

| |     |

| | |

|FAX |(   ) |

| |    - |

| |     |

| | |

|Email |      |

|Website (URL) |      |

|E-File Provider |      |

|Number (EFIN) | |

| | |

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