Form CA2 "Biographical Statement & Consent Collection Agency Application Form" - Idaho

What Is Form CA2?

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

Form Details:

  • Released on July 1, 2016;
  • The latest edition provided by the Idaho Department of Finance;
  • 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 printable version of Form CA2 by clicking the link below or browse more documents and templates provided by the Idaho Department of Finance.

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Download Form CA2 "Biographical Statement & Consent Collection Agency Application Form" - Idaho

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COLLECTION BIOGRAPHICAL STATEMENT & CONSENT FORM
FORM CA2 INSTRUCTIONS
A. GENERAL INSTRUCTIONS
1. FILING – Form(s) CA2 must accompany Form CA1, the Collection Agency License Application form.
Each individual identified as a control person for the applicant on Schedule A of Form CA1, must
complete Form CA2. Additionally, applicants/licensees must update the roster of control persons on Form
CA1 by filing a Schedule C, thus requiring additional CA2 forms.
2. EMPLOYMENT REPRESENTATION – The employment representation section must be completed by an
authorized representative of the applicant/licensee.
3. TERMS USED – See the following Explanation of Terms section regarding italicized words/phrases.
4. DATES – The filing date is the date applicant submits this form to the Department. The desired effective
date is the date applicant would like an amendment to become effective.
5. AMENDMENTS – The applicant must update biographical information by submitting amendments using
Form CA2. On Form CA2, circle or otherwise identify the item being amended. Complete only items 1(A)
and 1(I), as well as the information that is being amended.
B. FILING INSTRUCTIONS
1. FORMAT
A. Each individual identified as a control person on Schedules A or C must complete Form CA2. A fully
completed Form CA2 for each control person is required to be submitted along with the applicant’s
initial Form CA1. Form CA2 also accompanies Schedule C when reporting new control person(s).
B. Type or print all information clearly and legibly.
C. Use only the current version of Form CA2.
D. The Acknowledgment & Consent section must include a notarized original manual signature.
E. The Employment Representation section must include an original manual signature.
F. Employment history, item 6: provide the full legal name of the company, beginning with your current
employer. For the purposes of this history, include both 1099 independent contractor assignments as
well as W-2 status employment.
2. ATTACHMENTS -
A. Agents, including Responsible Persons in Charge (RPIC) of the applicant/licensee who will contact
persons in Idaho, whether debtors or creditors, relative to the business activities of the
applicant/licensee will need to be registered on the Notification of Agents/Collectors.
B. Provide written explanations and supporting documents for any “Yes” answer provided in section 8.
C.
EXPLANATION OF TERMS – The following terms are italicized throughout Form CA2
1. GENERAL
APPLICANT – The collection agency, debt/credit counselor, debt settlement company, debt buyer or
credit repair organization applying on or amending information on Form CA1 (including schedules) or
Form CA3. The only instance in which the applicant is an individual is in the case of a sole proprietorship.
CONTROL – The power, directly or indirectly, to direct the management or policies of a company,
whether through ownership of securities, by contract, or otherwise. Any person that (i) is a director,
general partner or executive officer; (ii) directly or indirectly has the right to vote 10% or more of a class of
a voting security or has the power to sell or direct the sale of 10% or more of a class of voting securities;
(iii) in the case of an LLC, Managing Member; or (iv) in the case of a partnership, has the right to receive
upon dissolution, or has contributed, 10% or more of the capital, is presumed to control that company.
CONTROL PERSON – An individual (a natural person) named on Form CA1 in Item 1A or in Schedules
A, B, or C that directly or indirectly exercises control over the applicant. This includes all RPICs.
Form CA2 Rev 7/2016
Page 1 of 6
COLLECTION BIOGRAPHICAL STATEMENT & CONSENT FORM
FORM CA2 INSTRUCTIONS
A. GENERAL INSTRUCTIONS
1. FILING – Form(s) CA2 must accompany Form CA1, the Collection Agency License Application form.
Each individual identified as a control person for the applicant on Schedule A of Form CA1, must
complete Form CA2. Additionally, applicants/licensees must update the roster of control persons on Form
CA1 by filing a Schedule C, thus requiring additional CA2 forms.
2. EMPLOYMENT REPRESENTATION – The employment representation section must be completed by an
authorized representative of the applicant/licensee.
3. TERMS USED – See the following Explanation of Terms section regarding italicized words/phrases.
4. DATES – The filing date is the date applicant submits this form to the Department. The desired effective
date is the date applicant would like an amendment to become effective.
5. AMENDMENTS – The applicant must update biographical information by submitting amendments using
Form CA2. On Form CA2, circle or otherwise identify the item being amended. Complete only items 1(A)
and 1(I), as well as the information that is being amended.
B. FILING INSTRUCTIONS
1. FORMAT
A. Each individual identified as a control person on Schedules A or C must complete Form CA2. A fully
completed Form CA2 for each control person is required to be submitted along with the applicant’s
initial Form CA1. Form CA2 also accompanies Schedule C when reporting new control person(s).
B. Type or print all information clearly and legibly.
C. Use only the current version of Form CA2.
D. The Acknowledgment & Consent section must include a notarized original manual signature.
E. The Employment Representation section must include an original manual signature.
F. Employment history, item 6: provide the full legal name of the company, beginning with your current
employer. For the purposes of this history, include both 1099 independent contractor assignments as
well as W-2 status employment.
2. ATTACHMENTS -
A. Agents, including Responsible Persons in Charge (RPIC) of the applicant/licensee who will contact
persons in Idaho, whether debtors or creditors, relative to the business activities of the
applicant/licensee will need to be registered on the Notification of Agents/Collectors.
B. Provide written explanations and supporting documents for any “Yes” answer provided in section 8.
C.
EXPLANATION OF TERMS – The following terms are italicized throughout Form CA2
1. GENERAL
APPLICANT – The collection agency, debt/credit counselor, debt settlement company, debt buyer or
credit repair organization applying on or amending information on Form CA1 (including schedules) or
Form CA3. The only instance in which the applicant is an individual is in the case of a sole proprietorship.
CONTROL – The power, directly or indirectly, to direct the management or policies of a company,
whether through ownership of securities, by contract, or otherwise. Any person that (i) is a director,
general partner or executive officer; (ii) directly or indirectly has the right to vote 10% or more of a class of
a voting security or has the power to sell or direct the sale of 10% or more of a class of voting securities;
(iii) in the case of an LLC, Managing Member; or (iv) in the case of a partnership, has the right to receive
upon dissolution, or has contributed, 10% or more of the capital, is presumed to control that company.
CONTROL PERSON – An individual (a natural person) named on Form CA1 in Item 1A or in Schedules
A, B, or C that directly or indirectly exercises control over the applicant. This includes all RPICs.
Form CA2 Rev 7/2016
Page 1 of 6
JURISDICTION – A state, the District of Columbia, the Commonwealth of Puerto Rico, any territory of the
United States, or any subdivision or regulatory body thereof.
PERSON – An individual, partnership, corporation, trust, LLC, or other organization.
2. FOR THE PURPOSE OF ITEM 8
ENJOINED – Includes being subject to a mandatory injunction, prohibitory injunction, preliminary
injunction, or a temporary restraining order.
FELONY – For jurisdictions that do not differentiate between a felony and a misdemeanor, a felony is an
offense punishable by a sentence of at least one year imprisonment and/or a fine of at least $1,000. The
term also includes a general court martial.
FINANCIAL SERVICES OR FINANCIAL SERVICES-RELATED – Pertaining to securities, commodities,
banking, insurance, consumer lending, or real estate (including, but not limited to; acting as or being
associated with a bank or savings association, credit union, mortgage lender, mortgage broker, real estate
salesperson or agent, closing agent, title company, or escrow agent).
FOREIGN FINANCIAL REGULATORY AUTHORITY – Includes (1) a financial services authority of a
foreign country; (2) other governmental body empowered by a foreign government to administer or
enforce its laws relating to the regulation of financial services or financial services-related activities; and
(3) a foreign membership organization, a function of which is to regulate the participation of its members
in financial services activities listed above.
FOUND – Includes adverse final actions, including consent decrees in which the respondent has neither
admitted nor denied the findings, but does not include agreements, deficiency letters, examination reports,
memoranda of understanding, letters of caution, admonishments, and similar informal resolutions of
matters.
INVOLVED – Doing an act or omission or aiding, abetting, counseling, commanding, inducing, conspiring
with or failing reasonably to supervise another in doing an act or omission.
MISDEMEANOR – For jurisdictions that do not differentiate between a felony and a misdemeanor, a
misdemeanor is an offense punishable by a sentence of less than one year imprisonment and/or a fine of
less than $1,000. The term also includes a special court martial.
ORDER – A written directive issued pursuant to statutory authority and procedures, including orders of
denial, suspension, or revocation; does not include special stipulations, undertakings or agreements
relating to payments, limitations on activity or other restrictions unless they are included in an order.
PROCEEDING – Includes a formal administrative or civil action initiated by a governmental agency, self-
regulatory organization or a foreign financial regulatory authority; a felony criminal indictment or
information (or equivalent formal charge); or a misdemeanor criminal information (or equivalent formal
charge). The term does not include other civil litigation, investigations, or arrests or similar charges
affected in the absence of a formal criminal indictment or information (or equivalent formal charge).
Form CA2 Rev 7/2016
Page 2 of 6
BIOGRAPHICAL STATEMENT & CONSENT
FORM CA2
COLLECTION AGENCY APPLICATION FORM
Date of filing (MM/DD/YYYY): ______
Desired Effective Date (MM/DD/YYYY): ________
License Number information (if
License #
Jurisdiction
License #
Jurisdiction
License #
Jurisdiction
applicable) is optional. Use
additional sheets if necessary.
License #
Jurisdiction
License #
Jurisdiction
License #
Jurisdiction
NEW APPLICATION
AMENDMENT To amend, circle or identify items being amended.
1.
Individual’s identifying information:
(A) Full last, first and middle names:
__________________________
________________________
_______________________
__________
Last Name
First Name
Full Middle Name
Suffix (if any)
(B) Social Security Number: ___________________
(C) Gender:
Male
Female
(D) Date of Birth (MM/DD/YYYY) ______
(E) State/Province of Birth: _________
(F) Country/Province of Birth: _____
(G) List all names(s) , other than your legal name, you have used or are using, or by which you are or were known since the age of
18. This field should include, for example, nicknames, aliases, and names used before or after marriage. (Use additional sheets
as necessary).
Name ____________________
Name ______________
Name __________________
Name ___________________
(H) For amendments only: If this filing reports that an individual’s name has changed, enter the new name and attach supporting
legal documentation:
______________________________
________________________
______________________
__________
Last Name
First Name
Full Middle Name
Suffix (if any)
(I)
Current Employer Name (applicant/licensee): ______________________________________________________________
(J) Physical Office of Employment address: (do not use a P.O. Box)
If this address is your private
residence, check this box.
________________________
_______________________
______________________
__________________
Number & Street
City
State / Province & Country
Zip+4 / Postal Code
(K) Current Residence address (if different from employment address):
________________________
_______________________
______________________
__________________
Number & Street
City
State / Province & Country
Zip+4 / Postal Code
(L) Telephone Numbers and e-mail address:
(_____)___________
(_____)_____________
(______)______________
(_____)_____________
Cell Phone (optional)
Fax Line
e-mail address
Business Phone
2.
Individual’s Acknowledgment & Consent:
I swear or affirm that I have executed this form before a Notary Public, of my own free will and:
(A) I have read and understand the items and instructions on this form;
(B) My answers (including attachments) are true and complete to the best of my knowledge;
(C) I understand that I am subject to administrative, civil or criminal penalties if I give false or misleading answers;
(D) I authorize all my current and former employers, law enforcement agencies, and any other person to furnish to any jurisdiction, or
any agent acting on its behalf, any information they have, including without limitation my creditworthiness, character, ability, business
activities, educational background, general reputation, history of my employment and, in the case of former employers, complete
reasons for my termination;
(E) I have read and understand applicable federal and state law, and will be in compliance at all times;
(F) I promise to keep the information contained in this form current and to file accurate supplementary information on a timely basis.
_____________________________
_______________________________
Date (MM/DD/YYYY)
Signature of individual
by _____________________________
Signed or attested before me: ____________________
Print Notary Public name
Print individual’s name
Notary seal here
on this ___________
day of __________,
________
at ______
__________
Date
Month
Year
State
County
____________________________________________
_______________________________
Notary Public signature
Notary Appointment Expires (MM/DD/YYYY)
Individual’s Acknowledgment & Consent must always be completed in full with original, manual signature and notarization.
Affix notary stamp or seal where applicable.
Form CA2 Rev 7/2016
Page 3 of 6
Applicant full legal name: ______________________________Individual’s full legal name:
________________
3.
Employer’s Representation:
To the best of my knowledge and belief, the control person will be familiar with the statutes, regulations, and rules of the jurisdiction
where this application is being filed, and will be fully qualified for the position for which application is being made herein. I have taken
appropriate steps to verify the accuracy and completeness of the information contained in and with this application. I have provided the
individual an opportunity to review the information contained herein and the individual has approved this information and signed the
form.
__________________________________
by ________________________________
________________________________
Company Name
Signature of authorized party
Print Name and Title of authorized party
Employment Representation must always be completed in full with original, manual signature.
4.
Fingerprint Information filing representation: (Not required to be filed in Idaho at this time)
I represent that I am submitting, have submitted, or promptly will submit to the appropriate jurisdiction(s) two fingerprint cards as
required.
X I am applying for a license in a jurisdiction that does not require me to submit fingerprint cards.
5.
Residential History: Starting with current address provide all residential addresses over the last ten years. Records must
contain a complete ten years history without gaps.
(Attach additional sheets as necessary.)
From
To
Street Address
City
State or
Zip or
Country/
(MM/YYYY)
(MM/YYYY)
Province
Postal
Province
Code
6.
Employment History: Provide a complete employment history for the past 10 years. Account for all time including full & part-
time employments, self-employment, military service, and homemaking. Also include periods such as unemployed, full-time
student, extended travel, etc. Indicate by “YES” or “NO” whether this employment was related to collection, debt/credit
counseling, debt settlement, debt buying, credit repair or any financial service-related business. Records must contain a
complete 10 year history without gaps. (Attach additional sheets as needed.)
From
To
Employer
Position Held (no
Address/City
State and
Country/
YES or
(MM/YYYY)
(MM/YYYY)
(company name)
abbreviations)
Postal Code
Province
NO?
Form CA2 Rev 7/2016
Page 4 of 6
Applicant full legal name: ______________________________
Individual’s full legal name: ______________________________
7. Other Business: Are you currently engaged in any other business either as a proprietor, partner, officer, director,
YES
NO
employee, trustee, agent or otherwise? (Please exclude activity that is exclusively charitable, civic, religious, or
fraternal and is recognized as tax exempt.) If YES, provide the following details: the name of the other business;
whether the business is related to collection, debt/credit counseling, debt buying, credit repair or any financial
service-related business; the address of the other business; the nature of the other business; your position, title, or
relationship with the other business; the start date of your relationship; the approximate number of hours per month
you devote to the other business; and briefly describe your duties relating to the other business. (Attach additional
sheets as needed.)
Details:
8.
Disclosures: If the answer to any of the following is “YES,” provide complete details of all events or proceedings as well as
supporting documents. Send the details on a separate sheet to the Department together with this application. Remember to file
updates to these disclosures as needed to keep the information current.
Financial Disclosure
YES
NO
(A) Within the past 10 years:
(1) have you filed a personal bankruptcy petition or been the subject of an involuntary bankruptcy petition?
(2) based upon events that occurred while you exercised control over any organization, have any filed a
bankruptcy petition or been the subject of an involuntary bankruptcy petition?
(B) Has a bonding company ever denied, paid out on, or revoked a bond for you?
(C) Do you have any unsatisfied judgments or liens against you?
Criminal Disclosure
(D) Within the past ten (10) years, have you been convicted of or pled guilty or nolo contendere ("no contest") in a
domestic, foreign, or military court to any felony?
(E)
Based upon activities that occurred while you exercised control over it, has an organization within the past ten
(10) years been convicted of or pled guilty or nolo contendere ("no contest") in a domestic, foreign, or military
court to any felony?
(F) Have you been convicted of or pled guilty or nolo contendere ("no contest") in a domestic, foreign, or military
court within the past ten (10) years to a misdemeanor involving: collection, debt/credit counseling, debt
settlement, debt buying, credit repair, OR any financial services-related business; any fraud, false statements,
or omissions; any theft or wrongful taking of property; bribery; perjury; forgery; counterfeiting; extortion; or a
conspiracy to commit any of these offenses?
(G) Based upon activities that occurred while you exercised control over it, has an organization within the past ten
(10) years been convicted of or pled guilty or nolo contendere ("no contest") in a domestic, foreign, or military
court to a misdemeanor specified in 8(F)?
Form CA2 Rev 7/2016
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