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 FORMMUST be completed.
5. In all instances the INFORMATION FORMMUST 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 NameTelephone No.
Contact Person:______
Fax No.FEIN
Website Address:______E-Mail Address:______
Application Prepared By: ______
Licensed Address:______
Street
______
CityStateZip CodeCounty
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 FormsManagementCenter.
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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
______
CityStateZip Code
Subscribed and sworn to before me this ______day of ______, 20_____
Notary Public______
(NOTARY SEAL) My Commission Expires: ______
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MULTIPLE LICENSED LOCATIONS
SALES FINANCE AGENCY ACT
Must be completed in the event of multiplelicenses:
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 $ _