Legal Name Illinois by AliceBegovich


									               ILLINOIS DEPARTMENT OF
               DEAN MARTINEZ, SECRETARY                                               ROD R. BLAGOJEVICH, GOVERNOR


                                              IMPORTANT NOTICE
This State agency is requesting disclosure of information that is necessary to determine compliance with the
Residential Mortgage License Act of 1987 and the Commissioners Rules promulgated thereto (205 ILCS 635/4-1, 4-4).
Reporting of this information is MANDATORY (205 ILCS 635/4-4). Failure to provide the information could result in a
fine, the revocation or suspension of your license, or the issuance of a reprimand (205 ILCS 636/4-5). In addition,
failure to report the requested information may adversely affect any attempt you may make to renew your license
(205 ILCS 635-2-6). A Licensee who deliberately, willfully or knowingly makes, subscribes or causes to be made any
false entry in this Notice with intent to deceive shall be guilty of a class 4 felony (205 ILCS 635/4-4). This form has
been approved by the State Forms Management Center.

                                          FILING INSTRUCTIONS

The application for change of name shall be filed at least ten (10) days prior to the proposed
effective date of the change (Section 1050.480 of Title 38, Chapter II of the Illinois
Administrative Code). A fee of $50.00, in the form of a certified check, company check or
money order, payable to the Illinois Department of Financial and Professional Regulation
(IDFPR), shall accompany the application; Print your current mortgage banking license name
and number and note: change of name in the memo section of the certified check or money
order. The original license with the current name must be returned along with the
aforementioned application and fee.

As part of the application the applicant is required to submit the applicable items noted on the
application checklist (page two of the instructions) along with the remittance advice when
submitting the package. The application items must be stacked in the order of the checklist. All
fees are processed in our Springfield office; please mail the payment and the completed
application to IDFPR, Attn: Name Change, 500 East Monroe Street, 11th Floor, Springfield, IL
62701. Do not submit application to the Chicago office this will only delay the process. Licensing
functions are executed in the Mortgage Banking Section; all questions should be directed to 312-
793-1409/fax 312-793-1490/TDD 312-793-0291.

Please note once the license is approved by the Division of Banking the licensee must update all
disclosures, this includes the "Loan Broker Disclosure", (Section 1050.1020(b) of Title 38,
Chapter II of the Illinois Administrative Code). The "Loan Broker Disclosure" requires the
disclosure of any other names under which the licensee has engaged in activities regulated by
the Act, even if not licensed under the current or predecessor Act, during the preceding 10 years
and, if applicable, the name of the parent or affiliated company.

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                                                        CHANGE OF NAME CHECKLIST

The applicant is required to submit the applicable items; an incomplete application will delay the

           Signed and dated application.

           Attach required $50 filing fee (certified check, company check or money order).
           Indicate on the face of your payment your current license name and number.

           Attach your original, current license.

           Attach a notarized affidavit, if original license has been misplaced with an

           Attach amended Certificate of Authority, if foreign corporation.

           Attach D/B/A Certificate from the Illinois Secretary of State, if using assumed name.
           (Be advised the name as it appears on the license must be the name used for: all
           disclosures, advertisements, answering phones, etc.)

           Attach amended Articles of Incorporation/Organization if changing legal name.

           Attach amended surety bond.

           Attach amended fidelity bond if required.

Effective Date of Application:

Remittance Request for Change of Name:

Licensee Name:

Licensee Number:

Change of Name Fee:                          $50.00

Amount Enclosed:
                                             Payable to the Illinois   Department   of   Financial   &
Payment Method:
                                             Professional Regulation

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                                             APPLICATION FOR CHANGE OF NAME

                        APPLICATION INFORMATION
Application must be typed. An illegible application will not be processed. If this occurs
the application will be mailed back to the licensee.

MB License Number:

Check Current Type of Name:                D/B/A                      Legal Name

Legal Name:

Company FEIN Number

License Address:

City, State, Zip:

Office Phone Number:                                      Office Fax:

Proposed Name Change:

(Please Note: The use of Federal and or Bank will not be allowed. Name must be
registered and approved by the State of Illinois Secretary of State.)

Check Proposed Change Type:          D/B/A             Legal Name

Was the Name approved by the State of Illinois- Secretary of State?      Yes       No

Reason for Change:

List Contact Person:

(Please note: contact person must be authorized to make a decision)


Contact Phone Number:

Contact Person Email:

Effective Date for Name Change:

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                                         APPLICATION FOR CHANGE OF NAME

Individual Completing Application

Print Name:




Phone Number:


Signature(s) of person(s) required to execute this form in accordance with Title 38,
Chapter II, Part 1050 of the Illinois Administrative Code: (Owner/President/Authorized

Print Name                                         Title

Signature                                          Date

Print Name                                         Title

Signature                                          Date

Print Name                                         Title

Signature                                          Date

For Internal Purposes Only:
Application Received:
Date Initial Review:
Date Final Acceptance/Rejection:
Rejection Reason:
Notice Date to Licensee:

                              Print               Reset Form

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