Form DBO-EL17213 "Request for Consent to Transfer an Interest in an Escrow Agent's License" - California

What Is Form DBO-EL17213?

This is a legal form that was released by the California Department of Financial Protection and Innovation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2017;
  • The latest edition provided by the California Department of Financial Protection and Innovation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DBO-EL17213 by clicking the link below or browse more documents and templates provided by the California Department of Financial Protection and Innovation.

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Download Form DBO-EL17213 "Request for Consent to Transfer an Interest in an Escrow Agent's License" - California

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STATE OF CALIFORNIA –DEPARTMENT OF BUSINESS OVERSIGHT
REQUEST FOR CONSENT TO TRANSFER AN INTEREST IN AN ESCROW
AGENT’S LICENSE
DBO–EL 17213 (Rev. 5-17)
Department of Business Oversight’s File No ________________________
1. (a) Name of Escrow Agent:_____________________________________________
(b) Former Name, if any: _______________________________________________
2. Description of interest(s) and number proposed to be transferred:
(State title of each class of interests (e.g., Class A Common Stock). If rights, warrants and options
are listed, also specify the securities to be transferred upon exercise thereof. If securities are to be
pledged, so state.)
______________________________________________________________________
______________________________________________________________________
3. Name and address of each transferor:
(If space is insufficient, incorporate and attach additional sheets.)
Percentage to Total
Aggregate Number
Number
to be Transferred
Name
Address
Outstanding
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
4. Name and address of each proposed transferee:
(If space is insufficient, incorporate and attach additional sheets.)
Percentage to Total
Aggregate Number
Number
to be Transferred
Name
Address
Outstanding
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
5. Address of principal executive office of Escrow Agent:
______________________________________________________________________
(Number and Street)
(City)
(State)
(Zip Code)
STATE OF CALIFORNIA –DEPARTMENT OF BUSINESS OVERSIGHT
REQUEST FOR CONSENT TO TRANSFER AN INTEREST IN AN ESCROW
AGENT’S LICENSE
DBO–EL 17213 (Rev. 5-17)
Department of Business Oversight’s File No ________________________
1. (a) Name of Escrow Agent:_____________________________________________
(b) Former Name, if any: _______________________________________________
2. Description of interest(s) and number proposed to be transferred:
(State title of each class of interests (e.g., Class A Common Stock). If rights, warrants and options
are listed, also specify the securities to be transferred upon exercise thereof. If securities are to be
pledged, so state.)
______________________________________________________________________
______________________________________________________________________
3. Name and address of each transferor:
(If space is insufficient, incorporate and attach additional sheets.)
Percentage to Total
Aggregate Number
Number
to be Transferred
Name
Address
Outstanding
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
4. Name and address of each proposed transferee:
(If space is insufficient, incorporate and attach additional sheets.)
Percentage to Total
Aggregate Number
Number
to be Transferred
Name
Address
Outstanding
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
5. Address of principal executive office of Escrow Agent:
______________________________________________________________________
(Number and Street)
(City)
(State)
(Zip Code)
STATE OF CALIFORNIA –DEPARTMENT OF BUSINESS OVERSIGHT
REQUEST FOR CONSENT TO TRANSFER AN INTEREST IN AN ESCROW
AGENT’S LICENSE
DBO–EL 17213 (Rev. 5-17) Page 2 of 3
6. Name and address of person to whom correspondence regarding this request for
consent should be directed:
_____________________________________________________________________
(Name)
(Number and Street)
(City)
(State)
(Zip Code)
7. Execution Instructions:
If a transferor is other than an individual, the name of the entity should be typed
or printed above the signature line exactly as shown in Item 3. The signature should
show the name and title of the person authorized to sign for such transferor.
I/We certify (or declare) under penalty of perjury under the laws of the State of
California that I/we have read this notice and know the contents thereof, and that the
statements herein are true and correct.
Executed at ___________________________, _________________________
(Place)
(Date)
(If the transferor is other than an individual, give the name of the entity and the name
and title of the person executing the application on behalf of such entity.)
________________________________
________________________________
(Signature of Transferor)
(Signature of Transferee)
________________________________
________________________________
(Signature of Transferor)
(Signature of Transferee)
________________________________
________________________________
(Signature of Transferor)
(Signature of Transferee)
STATE OF CALIFORNIA –DEPARTMENT OF BUSINESS OVERSIGHT
REQUEST FOR CONSENT TO TRANSFER AN INTEREST IN AN ESCROW
AGENT’S LICENSE
DBO–EL 17213 (Rev. 5-17) Page 3 of 3
DBO’s Privacy Notice on Collection
DBO Collects and Uses Personal Information: The DBO collects the information
requested on this form as authorized by the California Financial Code section 17213.
The DBO uses this information for request for consent to transfer an ownership interest
in an escrow agent’s license and for the Department to have knowledge of the type and
number of securities that are being transferred. Use of the personal Information DBO
collects is subject to limitations contained in the Information Practices Act of 1977 and
other applicable state and federal laws.
Providing Personal Information Is Voluntary: You do not have to provide the
personal information requested. If you do not want to provide personal information,
such as your name, home address or home telephone number, you may remain
anonymous. However, we may not be able to contact you or help resolve your issue.
When providing information or documents, please do not include unrequested personal
information such as a Social Security number, driver’s license number, or financial
information.
DBO May Disclose Your Personal Information: We may share your personal
information with other federal, state or local law enforcement agencies or a self-
regulatory organization as authorized by law. Your personal information may also be
disclosed:
 In response to a Public Records Act request, as allowed by the Information
Practices Act.
 To another governmental agency as required by state or federal law.
 In response to a court order or administrative order, a subpoena or a search
warrant.
Your Access to Your Personal Information: You may review the records maintained
by DBO that contain your personal information. To request access, contact: DBO
Privacy Officer, 1515 K Street, Sacramento, CA 95814, (866) 275-2677.
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