"Application for Renewal - Debt-Management Services License" - Delaware

This Delaware-specific "Application for Renewal - Debt-Management Services License" is a document released by the Delaware Department of Justice.

Download the fillable PDF by clicking the link below and use it according to the applicable legal guidelines.

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Download "Application for Renewal - Debt-Management Services License" - Delaware

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State of Delaware
2016-____
2016-____
Consumer Protection Unit
Debt Management Initial Application
for official use only
for official use only
APPLICATION FOR RENEWAL
Debt-Management Services License
Only complete applications will be considered. You may attach additional pages as necessary. Please type or print
clearly in ink. Illegible applications will not be accepted.
Each applicant must submit all renewal information and documentation annually. The application must be filed no
fewer than 30 and no more than 60 days before the license expires. If you file a timely and complete application,
your license will remain effective until you are notified that the application for renewal has been denied and the
reasons for the denial.
Send the completed application to the Consumer Protection Unit, Department of Justice, 820 N. French St.,
Fifth Floor, Wilmington, DE 19801.
Part I. Fee
The renewal application is not complete unless you send a non-refundable fee in the amount of one thousand dollars
($1,000.00). Checks should be made payable to the Consumer Protection Fund.
Part II. Information
This is an application for renewal of your Debt Management Services License. You must disclose any changes from
your most recent application in Item 17 below in addition to the information specifically requested.
NOTE: Except as specifically designated herein by an asterisk (*), the information provided is available to the
public.
1. Name of applicant: __________________________________________________________________
2. Principal place of business: ____________________________________________________________
_____________________________________________________________________________________
3. Business telephone number(s): _________________________________________________________
4. Electronic mail address: _____________________________________________________________
5. Internet website address: ____________________________________________________________
6. 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 licensee, any officer, director, owner, agent or person
with access to the required trust account unless previously disclosed:
______________________________________________________________________________________
______________________________________________________________________________________
1
State of Delaware
2016-____
2016-____
Consumer Protection Unit
Debt Management Initial Application
for official use only
for official use only
APPLICATION FOR RENEWAL
Debt-Management Services License
Only complete applications will be considered. You may attach additional pages as necessary. Please type or print
clearly in ink. Illegible applications will not be accepted.
Each applicant must submit all renewal information and documentation annually. The application must be filed no
fewer than 30 and no more than 60 days before the license expires. If you file a timely and complete application,
your license will remain effective until you are notified that the application for renewal has been denied and the
reasons for the denial.
Send the completed application to the Consumer Protection Unit, Department of Justice, 820 N. French St.,
Fifth Floor, Wilmington, DE 19801.
Part I. Fee
The renewal application is not complete unless you send a non-refundable fee in the amount of one thousand dollars
($1,000.00). Checks should be made payable to the Consumer Protection Fund.
Part II. Information
This is an application for renewal of your Debt Management Services License. You must disclose any changes from
your most recent application in Item 17 below in addition to the information specifically requested.
NOTE: Except as specifically designated herein by an asterisk (*), the information provided is available to the
public.
1. Name of applicant: __________________________________________________________________
2. Principal place of business: ____________________________________________________________
_____________________________________________________________________________________
3. Business telephone number(s): _________________________________________________________
4. Electronic mail address: _____________________________________________________________
5. Internet website address: ____________________________________________________________
6. 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 licensee, any officer, director, owner, agent or person
with access to the required trust account unless previously disclosed:
______________________________________________________________________________________
______________________________________________________________________________________
1
2016-____
for official use only
7. How many Delaware residents enrolled in plans in the year preceding this renewal? _________________
8. How many Delaware residents completed plans in the year preceding this renewal? _________________
9. 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:
________________________________________________________________________
10. Disclose the total amount of money received by the applicant pursuant to the plans during the preceding 12
months from or on behalf of clients who reside in the State of Delaware and the total amount of money distributed to
creditors of those individuals during this same period:
Receipts:
_______________________________________________________________________________
Disbursements: _______________________________________________________________________________
11. Disclose, to the best of the applicant’s knowledge, the highest single day bank account balance of money
accumulated during the preceding six months pursuant to plans by or on behalf of clients who reside in the State of
Delaware and with whom the applicant has agreements:
______________________________________________________________________________________
12. Identify each person who has access to a trust account (See page 5 for Criminal History Affidavit):
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
13. If the applicant offers a debt settlement program, disclose, to the best of the applicant’s knowledge, the gross
amount of money accumulated during the preceding 12 months by or on behalf of individuals who reside in this
State and with whom the applicant has agreements:
______________________________________________________________________________________
______________________________________________________________________________________
14. Identify any other providers of debt management services to which the applicant’s refer individuals through
links on your web page or by other means:
_________________________________________________________________________________________
2
2016-____
for official use only
_________________________________________________________________________________________
15. Identify any affiliate of the applicant:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
16. Identify any agent of the applicant that provides debt management services to applicant’s clients residing in
Delaware and indentify those services:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
17. The following information has changed since the applicant’s most recent application:
_______________________________________________________________________________________
_______________________________________________________________________________________
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 the year preceding this application.
2. A surety bond in the amount of Fifty Thousand Dollars ($50,000) with a surety authorized to transact business in
Delaware or a statement that the previously provided bond is still in effect and continuous.
3. Evidence of insurance in the amount at least equal to the larger of Two-Hundred and Fifty Thousand Dollars
($250,000), or the highest daily balance of the trust account holding funds of Delaware residents during the six
months preceding this renewal application, 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. Evidence of accreditation by an independent accrediting organization approved by the Attorney General.
5. 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.
6. A copy of each form of agreement used with Delaware residents as required in 6 Del.C. §2419A.
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, §2406A or §2411A.
3
2016-____
for official use only
AFFIDAVIT
State of __________________________________)
) SS.
County of ________________________________)
I, the undersigned, swear or affirm that:
1.
I have carefully read this Application for renewal of a Debt Management Services License, including all
attachments and forms. The information contained herein is the product of a diligent and reasonable
investigation and is true, accurate and complete to the best of my information and belief;
2.
I am a high managerial agent of the Applicant acting with the authority of the Applicant; and
3.
I understand that if I intentionally made a false statement in this application, or if someone else made a
false statement that I know or believe to be false, I may be subject to criminal prosecution.
_______________________________________
Signature of Affiant
_______________________________________
Print Name of Affiant
______________________________________
Title
Sworn or affirmed and subscribed to before me this ______ of _____________________, 20_____.
_______________________________________
Notary Public
SEAL
My commission expires: ____________________
4
2016-____
for official use only
Your application cannot be processed until the criminal records affidavit or fingerprint cards has
been received for each officer, employee, or agent who has access to the trust account.
If you have sent in fingerprint cards in a previous application, you do not need to send in a
fingerprint card or criminal records report again. Instead, return the affidavit below with this
application.
CRIMINAL RECORDS AFFIDAVIT
AFFIDAVIT
State of __________________________________)
) SS.
County of ________________________________)
I, the undersigned, swear or affirm that:
1. I have not been convicted of a crime or suffered a civil judgment, involving dishonesty or the violation of state or
federal securities laws. 6 Del. C. § 2409A (b) (2).
2. I understand that if I intentionally made a false statement regarding my criminal history, or if someone else made
a false statement that I know or believe to be false, I may be subject to criminal prosecution.
_______________________________________
Signature of Affiant
_______________________________________
Print Name of Affiant
______________________________________
Title
Sworn or affirmed and subscribed to before me this ______ of _____________________, 20_____.
_______________________________________
Notary Public
SEAL
My commission expires: ____________________
5
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