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INSTRUCTIONS – DEBT ADJUSTER APPLICATION
Please read these instructions carefully before preparing your application.
GENERAL A SEPARATE APPLICATION FOR EACH FICTITIOUS OR
Applications for licenses must be completed on the enclosed TRADE NAME IS REQUIRED
forms. Incomplete applications will not be considered for You must submit a separate application for each fictitious or
processing until all outstanding items have been submitted and trade name intended to be used.
fees paid.
HELPFUL TIP. If you don't have access to the word processing
Use the available word processing versions of this application, if versions of this application and wish to submit the same
possible. Otherwise, please use a typewriter or print clearly in application for multiple fictitious/trade names, the following is a
blue or black ink. Legible photocopies with original signatures simple way for this to be accomplished. Complete an
are acceptable. All forms are to be fully completed. Type N/A or application, but leave Part I, question #2 and signature sections
Not Applicable where appropriate. When space is insufficient, a blank. Each time you want to apply for a fictitious/trade name,
separate page should be used. Information on inserted pages make a copy of this original and then fill in Part I, question #2
must be keyed by letter and number to the appropriate questions. and sign and date the copy.
The application, supplemental pages and other related
information shall be provided under oath and shall be filed at the SUBMITTING YOUR APPLICATION
address noted below. Be sure to mail your application to the address provided in the
box below. Faxed or electronically submitted applications are
Full names and addresses must be given, including zip codes not accepted.
and telephone numbers.
APPLICATION PROCESS
SOCIAL SECURITY NUMBERS Once a complete application is filed, a decision will be made
Federal law as set out in 42 U.S.C. §§ 405(c)(2)(C)(i), 654 and within 60 days.
666 requires us to obtain Social Security numbers in connection
with applications for occupational and professional licenses. FEES
Those Social Security numbers may then be used for the Investigation and license fees must be submitted along with the
purposes set forth in those statutes, including enforcement of application. Please make checks payable to the Vermont
spousal and child support orders and paternity determinations, Department of Banking.
and the administration of tax systems, and may be shared with
the agencies which have responsibility for those matters. Debt Adjuster License:
Applicants are required to provide Social Security numbers on Non Refundable Application Fee $ 250.00
the Tax and Child Support Certification in the license application License Fee $ 250.00
materials. Social Security numbers will not appear on the face of
the license, but will be kept on file by the Department with the BOND REQUIREMENTS
license information. All applicants for a debt adjuster license must provide a surety
bond in the amount of $50,000.00, or in such other amount as
Use of Social Security numbers for purposes of the further the commissioner may specify in writing.
background investigation in connection with the license, however,
is voluntary. Your permission to use your Social Security number CONFIDENTIAL MATERIAL
for this purpose is not a requirement for obtaining a license but in This Department receives frequent requests for access to public
most cases will make the background investigation easier to records. If any material the applicant submits is viewed as
complete. If you do not wish your Social Security number used confidential, it should be marked and submitted as such.
for this purpose you must so advise the Department by writing to Marking something confidential does not necessarily mean that
the address below on or before the date on which the application it will be treated as confidential under Vermont Law. Refer to
is submitted. Title 1, Vermont Statutes Annotated, Section 317 for the
definition of public records.
SIGNATURE
Be sure the application is signed and dated (unsigned
applications are returned). Make a copy for your files.
Vermont Department of Banking, Insurance, Securities &
Health Care Administration
Banking Division
89 Main Street; Drawer 20
Montpelier, VT 05620-3101
(802) 828-3307 (voice) / (802) 828-3306 (fax)
Web site: http://www.bishca.state.vt.us
Revised 7/2004
STATE OF VERMONT
Application for Debt Adjuster License
Vermont Statutes Annotated, Title 8, Chapter 133
Please read the important instructions before completing this application. Type or print clearly in ink.
PART I - APPLICANT DATA
1. EXACT LEGAL NAME OF APPLICANT:
2. FICTITIOUS OR TRADE NAME TO BE USED (if applicable):
3. PRINCIPAL PLACE OF BUSINESS (Number and Street):
City: State: Zip Code:
4. MAILING ADDRESS, if different from above:
City: State: Zip Code:
5. TELEPHONE NUMBER: 6. FACSIMILE NUMBER: 7. WEB SITE ADDRESS:
( ) - ( ) -
8. ORGANIZATION TYPE: NATURAL PERSON
PARTNERSHIP
LIMITED LIABILITY COMPANY (“LLC”)
CORPORATION
OTHER
9. STATE OR COUNTRY OF INCORPORATION/ORGANIZATION: 10. DATE OF INCORPORATION/ORGANIZATION:
11. DATE AUTHORIZED IN VERMONT, IF FOREIGN CORPORATION OR LLC:
12. NAME OF VERMONT REGISTERED AGENT: 13. ADDRESS (Number and Street, City, State, Zip Code): 14. TELEPHONE:
( ) -
15. NAME OF INDIVIDUAL RESPONSIBLE FOR APPLICATION:
16. ADDRESS (Number & Street): 17. ADDRESS (City, State, Zip Code):
18. TELEPHONE: 19. FAX NO.: 20. EMAIL:
( ) - ( ) -
PROVIDE THE FOLLOWING DOCUMENTATION:
21. TAX AND CHILD SUPPORT CERTIFICATION FORM
22. CERTIFIED COPY OF ORGANIZATIONAL PAPERS, i.e. Articles of Incorporation
23. CERTIFICATE OF GOOD STANDING FROM STATE OR COUNTRY IN WHICH APPLICANT IS INCORPORATED OR FORMED
24. CERTIFICATE OF AUTHORITY OR GOOD STANDING TO DO BUSINESS IN VERMONT, less than six months old
25. COPY OF CERTIFICATE OF TRADE NAME REGISTRATION, if applicable.
OFFICE USE ONLY
DATE RECEIVED APPLICANT ID
DATE ______________
DATA ENTERED ______________
PART II – PERSONS IN CONTROL OF THE APPLICANT
List the names, business addresses and percentages of equity held, if applicable, by any person in control of the
applicant, including anyone owning or controlling, directly or indirectly, the power to vote 10% or more of the
interests of the applicant. If the applicant is an LLC, list the names, business address and ownership interest of
all members holding an ownership interest of 10% or more of the LLC. If the applicant is a partnership, list the
names, business addresses, and partnership interest (%) of all partners.
NOTE: All persons listed below must submit completed Financial Reports, Biographical Reports and Authority to
Release Information forms.
1. NAME: PERCENTAGE HELD:
BUSINESS ADDRESS (Number and Street): City: State: Zip Code:
2. NAME: PERCENTAGE HELD:
BUSINESS ADDRESS (Number and Street): City: State: Zip Code:
3. NAME: PERCENTAGE HELD:
BUSINESS ADDRESS (Number and Street): City: State: Zip Code:
4. NAME: PERCENTAGE HELD:
BUSINESS ADDRESS (Number and Street): City: State: Zip Code:
5. NAME: PERCENTAGE HELD:
BUSINESS ADDRESS (Number and Street): City: State: Zip Code:
6. NAME: PERCENTAGE HELD:
BUSINESS ADDRESS (Number and Street): City: State: Zip Code:
PART III - EXECUTIVE OFFICERS AND MEMBERS OF THE GOVERNING BODY
Submit completed Biographical Reports and Authority to Release Information forms for each individual listed
below.
1. NAME: TITLE:
2. NAME: TITLE:
3. NAME: TITLE:
4. NAME: TITLE:
5. NAME: TITLE:
6. NAME: TITLE:
7. NAME: TITLE:
8. NAME: TITLE:
9. NAME: TITLE:
10. NAME: TITLE:
11. NAME: TITLE:
12. NAME: TITLE:
PART V - LIST OF PROPOSED LOCATIONS
WHERE THE APPLICANT PROPOSES TO ENGAGE VERMONT RESIDENTS IN DEBT ADJUSTMENT SERVICES
If space is insufficient, additional pages may be used.
Submit completed Biographical Reports and Authority to Release Information forms for each manager named
below.
1. NAME OF LOCATION:
NAME OF MANAGER: TELEPHONE NUMBER:
( ) -
LOCATION ADDRESS (Number and Street): City: State: Zip Code:
2. NAME OF LOCATION:
NAME OF MANAGER: TELEPHONE NUMBER:
( ) -
LOCATION ADDRESS (Number and Street): City: State: Zip Code:
PART VI - DESCRIPTION OF DEBT ADJUSTMENT SERVICES
All Applicants provide the following:
1. A description of any debt adjustment and related services previously provided by the applicant and those services
the applicant seeks to provide in Vermont.
2. A detailed business plan. This description should include information on staffing and internal organizational policies,
systems and procedures, all banking arrangements, and how the applicant will market its services, including scripts,
advertisements and other marketing materials.
3. A description of the nature and amount of the fees, or the method of calculating the fees paid by the debtor.
4. A blank copy of the contract to be used with the debtor.
PART VII - FINANCIAL INFORMATION
All Applicants provide the following:
1. A list of any criminal convictions of the applicant or any material litigation in which the applicant has been involved in
the ten-year period preceding the submission of the application. Include potential settlement amounts that could
affect the applicant’s financial position.
Check here if no criminal convictions.
Check here if no pending litigation.
2. The name and address of the federally insured financial institution through which a separate account is maintained
for the benefit of the debtors.
3. Audited financial statements and unconsolidated financial statements of the applicant and any person in control of
the applicant, for the most recent fiscal year and last two fiscal years. This information must include both statements
of condition and income and expense statements. If the applicant or any person in control is publicly traded, or the
subsidiary of a publicly traded company, please provide the Central Index Key (CIK) Number used for filing 10K and
10Q with the United States Securities Exchange Commission or similar documentation filed with the regulator of the
parent corporation’s domicile outside the United States. Additionally, for all applicants that are not publicly traded
corporations, any persons in control must complete and submit a Financial Information form, Biographical Report
and Authority to Release Information form as noted in Part II.
4. A copy of the applicant’s federal tax returns for the two-year period next preceding the application date.
5. Submit a surety bond of not less than $50,000.00.
PART VIII - STATEMENTS
Addenda should be used by the applicant to report details of affirmative responses to the questions listed below.
YES NO
1. Does the applicant have any parent companies, subsidiaries, or affiliates? If yes, submit a list of all
affiliates of the applicant, including full exact name(s) of parent companies and subsidiaries, their
principal lines of business and if they are publicly traded. Also submit an organizational chart of all
parent/subsidiary relationships and ownership percentage of all affiliates.
2. Has the applicant or any of its affiliates, executive officers, members of its governing body, persons
in control, principal equity owners/partners, or beneficiaries (if the applicant is a trust) ever applied for a
license to the Commissioner of the Vermont Department of Banking, Insurance, Securities and Health
Care Administration or any other agency, to do business in Vermont?
3. Is the applicant, or any of its affiliates, executive officers, members of its governing body, persons in
control, principal equity owners/partners, or beneficiaries (if the applicant is a trust) conducting debt
adjustment business in any other state other than Vermont? If yes, provide: a) a list of other states in
which the applicant has held a license in the ten-year period next preceding submission of the
application to include the type of license held; b) a list of other states in which the applicant has applied
for a license to engage in debt adjustment; and, c) a list of all fictitious or trade names used outside of
Vermont by the applicant in the ten-year period next preceding submission of the application. Sign and
submit a Consent to Examine and Obtain Information form.
4. Has the Commissioner of Banking, Insurance, Securities and Health Care Administration, any other
agency of Vermont, any federal agency, or any agency of any other state ever denied, suspended, or
revoked the license or registration of the applicant, any of its affiliates, executive officers, members of
its governing body, persons in control, principal equity owners/partners, or beneficiaries (if the applicant
is a trust, to engage) in any regulated activity?
5. Has any governmental or regulatory agency ever initiated an informal or formal regulatory or
disciplinary action or order against the applicant, any of its affiliates, executive officers, members of its
governing body, persons in control, principal equity owners/partners, or beneficiaries (if the applicant is
a trust)?
6. Has the applicant, any of its affiliates, executive officers, members of its governing body, persons in
control, principal equity owners/partners, or beneficiaries (if the applicant is a trust) been enjoined or
restrained by order of any court from engaging in any conduct or practice related to debt adjustment?
7. Has the applicant, any of its affiliates, executive officers, members of its governing body, persons in
control, principal equity owners/partners, or beneficiaries (if the applicant is a trust) ever been convicted
of any crime in any jurisdiction in Vermont or elsewhere?
8. Has the applicant, any of its affiliates, executive officers, members of its governing body, persons in
control, principal equity owners/partners, or beneficiaries (if the applicant is a trust) ever filed for
bankruptcy protection or been subject to receivership proceedings?
PART IX - REFERENCES
List three business references who can attest to the character, reputation, experience, financial responsibility,
and general fitness of the applicant, at least one being a bank reference.
1. NAME OF REFERENCE: TELEPHONE NUMBER:
( ) -
ADDRESS (Number and Street): City: State: Zip Code:
2. NAME OF REFERENCE: TELEPHONE NUMBER:
( ) -
ADDRESS (Number and Street): City: State: Zip Code:
3. NAME OF REFERENCE: TELEPHONE NUMBER:
( ) -
ADDRESS (Number and Street): City: State: Zip Code:
PART X - CONTACT PERSONNEL
1. NAME OF PERSON RESPONSIBLE FOR FILING ANNUAL REPORT: TITLE:
BUSINESS ADDRESS (Number and Street): City: State: Zip Code:
TELEPHONE: FAX NO.: EMAIL:
( ) - ( ) -
2. NAME OF PERSON RESPONSIBLE FOR LICENSING AND RENEWAL: TITLE:
BUSINESS ADDRESS (Number and Street): City: State: Zip Code:
TELEPHONE: FAX NO.: EMAIL:
( ) - ( ) -
3. NAME OF PERSON RESPONSIBLE FOR CONSUMER COMPLAINTS: TITLE:
BUSINESS ADDRESS (Number and Street): City: State: Zip Code:
TELEPHONE: FAX NO.: EMAIL:
( ) - ( ) -
4. NAME OF PERSON RESPONSIBLE FOR REGULATORY AND EXAMINATIONS ISSUES: TITLE:
BUSINESS ADDRESS (Number and Street): City: State: Zip Code:
TELEPHONE: FAX NO.: EMAIL:
( ) - ( ) -
FOR THIS APPLICATION TO BE ACCEPTED FOR PROCESSING, YOU MUST SIGN AND DATE THIS APPLICATION
The undersigned, being duly sworn, states that he/she has executed the foregoing application under Title 8, Chapter 133
of Vermont Statutes Annotated; that he/she has been duly authorized to execute and file such application; and that to the
best of his/her knowledge, information, and belief, the application and accompanying materials contain no misstatement of
fact and do not omit a called for material fact.
__________________________________________
Date (mo./day/yr.) Signature
_
Name (Type or Print)
_
Title
(Applicant Seal)
State of )
County of )
On the day of in the year , before me personally appeared to
me known, who being sworn according to law, did depose and say he/she has read, signed, knows the contents of the
foregoing application including attached addenda, and that the statements contained in the application and attached
addenda are true and complete.
____________________________________
(Notary Public)
Commission Expires_____________________________
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