Form ICC2 "Idaho Consumer Lender Application Form" - Idaho

What Is Form ICC2?

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 February 1, 2019;
  • 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 ICC2 by clicking the link below or browse more documents and templates provided by the Idaho Department of Finance.

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Download Form ICC2 "Idaho Consumer Lender Application Form" - Idaho

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Mail:
Overnight:
Idaho Department of Finance
Idaho Department of Finance
P.O. Box 83720
800 Park Blvd., Ste 200
Boise, Idaho 83720-0031
Boise, Idaho 83712
208/332-8000
IDAHO CONTROL PERSONS INFORMATION
FORM ICC2 INSTRUCTIONS
A. GENERAL INSTRUCTIONS
1. FILING – Form ICC2 must accompany Form ICC1, the Regulated Consumer Lender Application form. Each individual,
identified as a control person for the applicant on Schedule A, must complete Form ICC2.
2. EMPLOYMENT REPRESENTATION – The employment representation section must be completed by an authorized
representative of the applicant (corporate officer, partner, member, sole proprietor, etc).
3. TERMS USED – See the following Explanation of Terms section regarding italicized words/phrases.
4. AMENDMENTS – The applicant must update information about a control person as required in each applicable jurisdiction
by submitting amendments using Form ICC2 in addition to Schedule C of Form ICC1. On Form ICC2, circle the item
being amended. Complete only the information that is being amended as well as the name of applicant and the name of
the control person. Idaho does not have additional fees for amendment filings.
B. FILING INSTRUCTIONS
A. Each individual identified as a control person on Schedules A or C must complete Form ICC2. A fully completed Form
ICC2 for each control person is required to be submitted to each jurisdiction along with the applicant’s initial Form
ICC1. Form ICC2 accompanies Schedule C when reporting new control person(s).
B. Employment history, item 5: provide the full legal name of the company, beginning with your current employer.
C. The Acknowledgment & Consent section must include notarized original manual signature.
D. The Consumer Lender Employment Representation section must include original manual signature and notary.
E. Type or print legibly all information.
F. Use only the current version of Form ICC2.
EXPLANATION OF TERMS – The following terms are italicized throughout Form ICC2
C.
1. GENERAL
APPLICANT – The finance entity applying on or amending information on this form. 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 officer exercising
executive responsibility (or having similar status or functions); (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; or (iii)
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 named on Form ICC1 in Item 1A or in Schedules A, B or C, that directly or indirectly
exercises control over the applicant.
PERSON – An individual, partnership, corporation, trust, or other organization.
2. FOR THE PURPOSE OF ITEM 6
CHARGED – Being accused of a crime in a formal complaint, information, or indictment (or equivalent formal charge).
ENJOINED – Includes being subject to a mandatory injunction, prohibitory injunction, preliminary injunction, or a
temporary restraining order.
Form ICC2, 2005 Rev 2/2019
Page 1 of 5
Mail:
Overnight:
Idaho Department of Finance
Idaho Department of Finance
P.O. Box 83720
800 Park Blvd., Ste 200
Boise, Idaho 83720-0031
Boise, Idaho 83712
208/332-8000
IDAHO CONTROL PERSONS INFORMATION
FORM ICC2 INSTRUCTIONS
A. GENERAL INSTRUCTIONS
1. FILING – Form ICC2 must accompany Form ICC1, the Regulated Consumer Lender Application form. Each individual,
identified as a control person for the applicant on Schedule A, must complete Form ICC2.
2. EMPLOYMENT REPRESENTATION – The employment representation section must be completed by an authorized
representative of the applicant (corporate officer, partner, member, sole proprietor, etc).
3. TERMS USED – See the following Explanation of Terms section regarding italicized words/phrases.
4. AMENDMENTS – The applicant must update information about a control person as required in each applicable jurisdiction
by submitting amendments using Form ICC2 in addition to Schedule C of Form ICC1. On Form ICC2, circle the item
being amended. Complete only the information that is being amended as well as the name of applicant and the name of
the control person. Idaho does not have additional fees for amendment filings.
B. FILING INSTRUCTIONS
A. Each individual identified as a control person on Schedules A or C must complete Form ICC2. A fully completed Form
ICC2 for each control person is required to be submitted to each jurisdiction along with the applicant’s initial Form
ICC1. Form ICC2 accompanies Schedule C when reporting new control person(s).
B. Employment history, item 5: provide the full legal name of the company, beginning with your current employer.
C. The Acknowledgment & Consent section must include notarized original manual signature.
D. The Consumer Lender Employment Representation section must include original manual signature and notary.
E. Type or print legibly all information.
F. Use only the current version of Form ICC2.
EXPLANATION OF TERMS – The following terms are italicized throughout Form ICC2
C.
1. GENERAL
APPLICANT – The finance entity applying on or amending information on this form. 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 officer exercising
executive responsibility (or having similar status or functions); (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; or (iii)
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 named on Form ICC1 in Item 1A or in Schedules A, B or C, that directly or indirectly
exercises control over the applicant.
PERSON – An individual, partnership, corporation, trust, or other organization.
2. FOR THE PURPOSE OF ITEM 6
CHARGED – Being accused of a crime in a formal complaint, information, or indictment (or equivalent formal charge).
ENJOINED – Includes being subject to a mandatory injunction, prohibitory injunction, preliminary injunction, or a
temporary restraining order.
Form ICC2, 2005 Rev 2/2019
Page 1 of 5
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 sales agent or broker, appraiser, 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, settlement,
cease and desist, suspension, or revocation; but 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 ICC2, 2005 Rev 2/2019
Page 2 of 5
CONTROL PERSONS INFORMATION
FORM ICC2
IDAHO CONSUMER LENDER APPLICATION FORM
Applicant full legal name:
:
WARNING
Failure to keep this form current and to file accurate supplementary information on a timely basis, or otherwise to comply with the provisions of
law pertaining to the conduct of business for which you are applying, may violate the laws of Idaho and may result in disciplinary, administrative,
injunctive or criminal action.
INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACTS MAY CONSTITUTE CRIMINAL VIOLATIONS.
APPLICATION
AMENDMENT
(
To amend, circle items being amended.)
Individual’s identifying information:
1.
A.
Full last, first and middle names:
Last name
First name
Full middle name
Suffix
B.
(1)
Social Security Number:
(2)
Gender:
Male
Female
C.
(1)
Date of Birth (MM/DD/YYYY)
:
(2)
State/Province of Birth:
(3)
Country of Birth
D.
List all other name(s) you have used or are using, or by which you are know or have been known, other than your legal name, since the age of 18.
This field should include for example, nicknames, aliases, and names used before/after marriage. (Use additional sheets as necessary).
1.
Name
2.
Name
3.
Name
4.
Name
(For amendments only) If this filing reports that an individual’s name has changed, enter the new name and attach supporting legal documentation
E.
Last name
First name
Full middle name
Suffix
F.
Office of Employment address: (Do not use a P.O. Box)
If this address is your private residence, check this box.
Number and Street
City
State/Country
Zip+4/Postal Code
G.
Current Residence address, if different:
Number and Street
City
State/Country
Zip+4/Postal Code
H.
Telephone Numbers and e-mail address:
Business phone
Fax line
Area Code
Telephone Number
Area Code
Telephone Number
Cell phone
Area Code
Telephone Number
e-mail address
CONTROL PERSON’S ACKNOWLEDGMENT & CONSENT:
I swear or affirm that I have read and understand the items and instructions on this form and that my answers (including attachments) are true and complete to
the best of my knowledge. I understand that I am subject to administrative, civil or criminal penalties if I give false or misleading answers. 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.
Date (MM/DD/YYYY)
Signature of Control Person
Signed or attested before me
by
Print Notary Public name
Print Control Person name
Notary seal here
on this
day of
,
at
Month
Year
State
County
Notary Public Signature
Notary Appointment Expires (MM/DD/YYYY)
CONSUMER LENDER EMPLOYMENT REPRESENTATION
To the best of my knowledge and belief, and at the time of approval, the control person will be familiar with the statutes, regulations, and rules of the
jurisdiction(s) with which 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 control person an
opportunity to review the information contained herein and the control person has approved this information and signed the form.
Date (MM/DD/YYYY)
Name of Consumer Lender (company)
By:
Signature of authorized party
Print Name
Title
Acknowledgment & Consent and Employment Representation sections must always be completed in full with original, manual signatures and
notarization. Affix notary stamp or seal where applicable.
Form ICC2, 2005 Rev 2/2019
Page 3 of 5
Individual’s full legal name:
Applicant full legal name:
2.
Fingerprint Information filing representation:
I represent that I am submitting, have submitted, or promptly will submit to the appropriate jurisdiction(s) two fingerprint cards as required.
Fingerprint Card Barcode(s):
XX I am applying as a control person only in jurisdiction(s) that do not require me to submit fingerprint card(s). Not required in IDAHO at this time.
3.
Residential History: Starting with current address (item 1G), give all addresses for the past 10 years. (Attach additional sheets as necessary.)
From
To
Street Address
City
State or
Zip or
Country
(MM/YYYY)
(MM/YYYY)
Province
Postal Code
4.
Employment History: Provide 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 financial service-related business. (Attach additional sheets as needed.)
YES or NO?
From
To
Employer
Position Held
City
State or
Country
(MM/YYYY)
(MM/YYYY)
(company name)
Province
5. Other Business: Are you currently engaged in any other business either as a proprietor, partner, officer, director, employee, trustee,
YES
NO
agent or otherwise? (Please exclude non-financial services-related 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
financial services-related; 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/month you devote to the other business; and
briefly describe your duties relating to the other business. (Attach additional sheets as needed.)
Details:
Disclosures: If the answer to any of the following is “YES”, provide complete details of all events or proceedings in an attachment. Refer to the
6.
explanation of terms section of the instructions for explanations of italicized terms.
Financial Disclosure
YES
NO
A. Within the past ten 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?
Form ICC2, 2005 Rev 2/2019
Page 4 of 5
Individual’s full legal name:
Applicant full legal name:
Criminal Disclosure
YES
NO
D. Have you ever 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 ever been convicted of or pled guilty or
nolo contendere ("no contest") in a domestic, foreign, or military court to any felony?
F. Have you ever been convicted of or pled guilty or nolo contendere ("no contest") in a domestic, foreign, or military court to a
misdemeanor involving: financial services or a financial services-related business or any fraud, false statements or omissions, theft or
any 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 ever been convicted of or pled guilty or
nolo contendere ("no contest") in a domestic, foreign, or military court to a misdemeanor specified in 6F?
Regulatory Action Disclosure
H. Has any State or federal regulatory agency or foreign financial regulatory authority ever:
(1) found you to have made a false statement or omission or been dishonest, unfair or unethical?
(2) found you to have been involved in a violation of a financial services-related regulation(s) or statute(s)?
(3) found you to have been a cause of a financial services-related business having its authorization to do business denied,
suspended, revoked or restricted?
(4) entered an order against you in connection with a financial services-related activity?
(5) denied, suspended, or revoked your registration or license, disciplined you, or otherwise by order, prevented you from associating
with a financial services-related business or restricted your activities?
(6) barred you from association with an entity regulated by such commission, authority, agency, or officer, or from engaging in a
financial services-related business?
(7) issued a final order based on violations of any law or regulations that prohibit fraudulent, manipulative, or deceptive conduct?
I. Have you ever had an authorization to act as an attorney, accountant, real estate agent, or state or federal contractor that was
revoked or suspended?
J. Are you now the subject of any regulatory proceeding that could result in a "yes" answer to any part of 6H or 6I?
Civil Judicial Disclosure
K. (1) Has any domestic or foreign court ever:
(a) enjoined you in connection with any financial services-related activity?
(b) found that you were involved in a violation of any financial services-related statute(s) or regulation(s)?
(c) dismissed, pursuant to a settlement agreement, a financial services-related civil action brought against you by a state, federal,
or foreign financial regulatory authority?
(2) Are you named in any pending financial services-related civil action that could result in a "yes" answer to any part of 6K(1)?
Customer Arbitration/Civil Litigation Disclosure
L. Have you ever been named as a respondent/defendant in a financial services-related consumer-initiated arbitration or civil litigation
which:
(1) is still pending; or
(2) resulted in an arbitration award or civil judgment against you, regardless of amount, or that required corrective action; or
(3) was settled for any amount?
Termination Disclosure
M. Have you ever voluntarily resigned, been discharged, or permitted to resign after allegations were made that accused you of:
(1) violating statute(s), regulation(s), rule(s), or industry standards of conduct?
(2) fraud, dishonesty, theft, or the wrongful taking of property?
Form ICC2, 2005 Rev 2/2019
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