"Initial Application Form - Debt-Management Services License" - Delaware

This "Initial Application Form - Debt-Management Services License" is a part of the paperwork released by the Delaware Department of Justice specifically for Delaware residents.

The latest fillable version of the document was released on February 3, 2012 and can be downloaded through the link below or found through the department's forms library.

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Download "Initial Application Form - Debt-Management Services License" - Delaware

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State of Delaware
2016-____
Consumer Protection Unit
for official use only
200
Debt Management Initial Application
INITIAL APPLICATION
Debt-Management Services License
Only applicants with complete applications are eligible for consideration. You may attach additional pages as
necessary. Please type or print clearly in ink. Illegible applications will not be accepted.
NOTE: All information and documentation must be submitted concurrently except that fingerprint cards and
authorization may be submitted prior to the application form in order to expedite the process. Applications must be
complete before they are submitted for consideration. Incomplete applications may be denied or returned to the
applicant. Send the completed application to the Consumer Protection Unit, Department of Justice, 820 N.
French St., Fifth Floor, Wilmington, DE 19801.
Part I. Fee.
An application is not complete unless you send a non refundable fee in the amount of two thousand dollars
($2,000.00). Checks should be made payable to the Consumer Protection Fund.
Part II. Information.
An application is not complete unless you have filled in all the blanks. If you do not have the information requested
(for example, if you do not have a web address), write “not applicable” or “N/A” in the blank. The words “you” and
“your” refers to the business entity making the application.
NOTE: Except as specifically designated herein by an asterisk (*), the information provided is available to the
public.
1. Name of applicant: __________________________________________________________________
2. Applicant is a(n): ____ Corporation;
____ Unincorporated Association;
_____ Partnership;
____ Limited Liability Company; _____ Limited Liability Partnership; _____ Sole Proprietorship; or
____ Other – specify: ________________________________________________________________
3. Applicant’s business is a: ______ For- Profit Enterprise
______ Non-Profit Enterprise
4. Principal place of business: ____________________________________________________________
_____________________________________________________________________________________
5. Business telephone number(s): _________________________________________________________
*Revised 2 3 12
1
State of Delaware
2016-____
Consumer Protection Unit
for official use only
200
Debt Management Initial Application
INITIAL APPLICATION
Debt-Management Services License
Only applicants with complete applications are eligible for consideration. You may attach additional pages as
necessary. Please type or print clearly in ink. Illegible applications will not be accepted.
NOTE: All information and documentation must be submitted concurrently except that fingerprint cards and
authorization may be submitted prior to the application form in order to expedite the process. Applications must be
complete before they are submitted for consideration. Incomplete applications may be denied or returned to the
applicant. Send the completed application to the Consumer Protection Unit, Department of Justice, 820 N.
French St., Fifth Floor, Wilmington, DE 19801.
Part I. Fee.
An application is not complete unless you send a non refundable fee in the amount of two thousand dollars
($2,000.00). Checks should be made payable to the Consumer Protection Fund.
Part II. Information.
An application is not complete unless you have filled in all the blanks. If you do not have the information requested
(for example, if you do not have a web address), write “not applicable” or “N/A” in the blank. The words “you” and
“your” refers to the business entity making the application.
NOTE: Except as specifically designated herein by an asterisk (*), the information provided is available to the
public.
1. Name of applicant: __________________________________________________________________
2. Applicant is a(n): ____ Corporation;
____ Unincorporated Association;
_____ Partnership;
____ Limited Liability Company; _____ Limited Liability Partnership; _____ Sole Proprietorship; or
____ Other – specify: ________________________________________________________________
3. Applicant’s business is a: ______ For- Profit Enterprise
______ Non-Profit Enterprise
4. Principal place of business: ____________________________________________________________
_____________________________________________________________________________________
5. Business telephone number(s): _________________________________________________________
*Revised 2 3 12
1
2016-____
for official use only
200
6. All business locations in Delaware: ______________________________________________________
_____________________________________________________________________________________
7. Electronic mail address: _______________________________________________________________
8. Internet website address: ______________________________________________________________
9. Name and address of your registered agent in Delaware: ______________________________________
______________________________________________________________________________________
______________________________________________________________________________________
10. Name, toll free telephone number, and electronic mail address of principal contact for consumer complaints:
______________________________________________________________________________________
______________________________________________________________________________________
11. All names under which the applicant conducts business:
______________________________________________________________________________________
______________________________________________________________________________________
12. The address of each location in Delaware where the applicant will provide debt-management services or check
the statement that the applicant “will have no location in Delaware”:
______________________________________________________________________________________
______________________________________________________________________________________
o
Applicant will have no location in Delaware.
13. The identity of each director who is an ‘affiliate’ of the applicant as defined in 6 Del. C. §2402A (1)(A) or
(B)(i), (ii), (iv), (v), (vi),or (vii):
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
14. The name and home address* of each officer, director, and owner of ten percent (10%) of the debt management
business:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
*Revised 2 3 12
2
2016-____
for official use only
200
15. A description of any ownership interest of at least ten percent (10%) by a director, owner, or employee of the
applicant in
(A) any ‘affiliate’ as defined in the licensing law _______________________________________
______________________________________________________________________________________
______________________________________________________________________________________
or (B) any entity that provides products or services to the applicant or any individual relating to the applicant’s
debt management services: ________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
16. Identify any agent of the applicant that provides debt management services to applicant’s clients residing in
Delaware and identify those services:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
17. The names, addresses and phone numbers of the employers of each director during the five (5) years preceding
the application. [Applicant may attach a resume that contains the required information and incorporate by
reference]:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
18. Identify every jurisdiction where the applicant, officer, or director has been licensed or registered to provide
debt-management services in the last five (5) years or where consumers of applicant’s debt management services
have resided:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
19. Identify any state in which applicant has been denied a license to provide debt management services.
______
______________________________________________________________________________
20. Provide a description of any material civil or criminal judgment or litigation, and any material administrative or
enforcement action by a governmental agency, against the applicant, any officer, director, owner, agent or person
with access to the required trust account:
______________________________________________________________________________________
______________________________________________________________________________________
*Revised 2 3 12
3
2016-____
for official use only
200
21. * IF the applicant is a ‘not for profit’ entity or has tax exempt status under 26 U.S.C. sec. 501, provide a
statement of the amount of compensation of the applicant’s five most highly compensated employees for each of the
three years preceding the application or the length of time applicant has provided debt management services,
whichever is shorter.
_____________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
22. With respect to the trust accounts the applicant has established for the purpose of holding clients’ money identify
all trust accounts containing funds from Delaware residents including the following information:
Name on the account:
_____________________________________________________________________
Location of the account:
_____________________________________________________________________
The account number:
_____________________________________________________________________
The dollar value:
_____________________________________________________________________
23. Identify each person who has access to a trust account.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Part III. Enclose the following documents.
An application is not complete and cannot be reviewed until the following documents are received:
1. * Financial statements audited by a Certified Public Accountant for two years preceding this application or the
length of time the applicant has been providing debt management services, whichever is less.
2. A surety bond in the amount of Fifty Thousand Dollars ($50,000), using the form provided herewith, with a
surety authorized to transact business in Delaware unless a higher amount is deemed necessary by the Attorney
General or an irrevocable letter of credit acceptable to the Attorney General.
3. Evidence of insurance in the amount of Two Hundred and Fifty Thousand Dollars ($250,000) against the risks of
dishonesty, fraud, theft, and other misconduct by a director, employee or agent of the applicant with no greater than
Five Thousand Dollars ($5,000) deductible. The insurer shall be licensed in Delaware and shall have a current
rating of at least “A” by a nationally recognized rating organization. The Attorney General shall appear on the
policy as an interested party entitled to notice of cancellation.
4. If the applicant has a trust account, an irrevocable consent authorizing the Attorney General, or designee, to
review and examine the trust account identified herein
5. Evidence of accreditation by an independent accrediting organization approved by the Attorney General.
*Revised 2 3 12
4
2016-____
for official use only
200
6. A description of the three most common educational programs provided for Delaware residents and a copy of the
educational materials.
7. Documentation of certification by a bona fide third-party certification provider approved by the Attorney General
for each certified counselor or a statement that such documentation will be provided within 12 months of
employment.
8. A description of the financial analysis and initial budget plan, including any form or electronic model, used to
evaluation the financial condition of individuals.
9. A copy of each form of proposed debt management plan agreement used with Delaware consumers as required in
6 Del.C. §2419A and the notice of right to cancel as provided in 6 Del.C. §2420.
10. If the internet is a component of a counseling session, provide a copy of all computer screens viewed by the
consumer.
11. A schedule of fees (including voluntary donations) for all services to be used with Delaware consumers.
Include initial and recurring fees for services and materials.
12. Proof of ‘good standing’ from the state in which the applicant is chartered or organized.
IV. Criminal Records Check
Your application cannot be processed until the complete criminal records check has been received
for each officer and each employee or agent who has access to the trust account. The Delaware State Bureau of
Identification is the intermediary and the Office of the Attorney General is the screening point for the receipt of the
criminal history records.
In order to expedite the application process, you may request fingerprint cards and authorization forms by
contacting the Consumer Protection Unit at (302) 577-8600 prior to submitting the completed application. You can
then take the fingerprint cards to a local law enforcement agency for fingerprinting.
The completed cards and authorization forms must be returned to the Consumer Protection Unit,
Department of Justice, 820 N. French St., Fifth Floor, Wilmington, DE 19801. Enclose the fee of $69.00 for each
criminal history. The fee must be paid by cashier’s check or money order payable to the Delaware State Police.
There may be an additional fee imposed by your local law enforcement agency when the fingerprints are taken.
A criminal records check obtained for the purpose of doing business in any state, that was issued within the
last 12 months and based on the fingerprints of the officer or person with access to the trust account, satisfies this
requirement if the criminal records check is provided to this office by the licensing state and received by that state
from a central repository.
THE APPLICANT SHALL UPDATE THE INFORMATION PROVIDED IN THIS APPLICATION
WITHIN 10 DAYS FOLLOWING ANY CHANGE IN THE INFORMATION REQUIRED BY 6 DEL.C.
§2405A or §2406A.
*Revised 2 3 12
5
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