Collection Agency Licensure Initial Application

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1 INSTRUCTIONS: Please refer to our Before You Begin handout. Complete all portions of this application for new licensure as a North Carolina collection agency. Responses to all requested information are required. It is imperative that you indicate N/A for items that are not applicable to your company. Incomplete applications cannot be processed. The non-refundable statutory licensing fee is $1,050.00; make check payable to the NC Department of Insurance. We invite you to visit our website at to view the rules and regulations for collection agencies, FAQ list, etc. SECTION 1: Company Demographics Section 1.1 ~ Contact Information Permit/License No. (NCDOI Internal Use Only): Legal : DBA/Trade (if applicable): Mailing Address (if different from above): Telephone Number: FAX Number: Business Contact : Direct Telephone: Business Address: Business Website: Home Office Mailing Address (if applicable): Home Office Telephone: Home Office Fax: Licensing Provider Contact (if applicable): Licensing Provider Section 1.2 ~ Agency Designation Designation refers to the state and/or country where incorporated; only companies incorporated in NC are classified domestic. [ ] Domestic = NC Corporation [ ]Foreign = Non-NC Corporation [ ]Alien = Non-U.S. Corporation/International

2 2 SECTION 2: Ownership/Related Activities Section 2.1 ~ Owners Provide both the percentage and name(s) of the individual(s) and/or entities with a 10% or greater ownership of the applicant. Each individual and/or owner(s) of entities must complete and submit a personal questionnaire NC Form DOI-5C. Section 2.2 ~ Governing Members Provide the names of Board of Directors, LLC Members, Partners or the Sole Proprietor with fiduciary responsibility to the applicant. Each individual and/or owner(s) of entities must complete and submit a personal questionnaire NC Form DOI-5C. Section 2.3 ~ Officers Provide the names of Officers, Senior Directors, Managing Members, Partners or the Sole Proprietor of the applicant. Each individual and/or owner(s) of entities must complete and submit a personal questionnaire NC Form DOI-5C.

3 3 Section 2.4 ~ Business Relationships Provide information on all companies the applicant has business relationships (i.e. parent company, subsidiaries, partnerships, affiliates, venture companies, etc.) Attach a flowchart/diagram showing the relationship amongst the businesses. SUBSIDIARY OF A PARENT COMPANY: a) Is applicant a subsidiary of a holding company system? ** b) Does applicant s parent co. regularly file financial information with the U.S. Securities & Exchange Commission? ** **If YES to both questions, the applicant may submit the parent company s audited financial statement in lieu of its own. However, the parent company must provide a written statement guaranteeing the financial performance of the applicant, along with the balance sheet. Parent Company : Attached: [ ] Audited Financials [ ] Financial Performance Guarantee OTHER BUSINESS RELATIONSHIPS: Relationship to Applicant: Business : Relationship to Applicant: Business : Section 2.5 ~ Similar Businesses Provide information on all companies managed by any of the listed owners, governing members and/or officers of the applicant. Similar businesses include companies and/or law firms engaged in collection activities. Individual s : Business : Equity/Managed %: Individual s : Business : Equity/Managed %:

4 4 Section 2.6 ~ Authorization to Apply for Collection Agency Permit Provide a certified/notarized copy of the Board of Directors resolution and/or Owner s authorization to specifically apply for a North Carolina collection agency permit/license. (per NCGS (b). SECTION 3: Legal Disclosures Section 3.1 ~ Attorney Information (a) Provide information on all attorneys who have been or will be hired to collect debts/receivables owned by the applicant; and (b) Provide information for any owners, governing members, and/or officers of the applicant who are attorneys. Relationship to Applicant: Business : Relationship to Applicant: Business : Relationship to Applicant: Business : Section 3.2 ~ Ethical Disclosures Provide an answer to all questions. Explanations are required for any question answered YES. (1) Has the applicant or any of its owners, governing members and/or officers ever been convicted of, or is currently charged with committing a crime, whether or not adjudication was withheld? For clarification purposes crime includes a misdemeanor, felony, or a military offense. Misdemeanor traffic citations and juvenile offenses are excluded. Convicted includes, but is not limited to, having been found guilty by verdict of a judge or jury, having entered a plea of guilty or nolo contendre, or having been given probation, a suspended sentence or a fine. If answered YES, attach a copy of the following documents: A. Written statement explaining the circumstances of each incident; B. Charging document; and C. Official document demonstrating the resolution of the charges or any final judgment

5 5 Section 3.2 ~ Ethical Disclosures (continued) Provide an answer to all questions. Explanations are required for any question answered YES. (2) Has the applicant or any of its owners, governing members and/or officers ever been involved in an administrative proceeding regarding any professional or occupational license? Involved means having a license censured, suspended, revoked, canceled, or terminated; or, being assessed a fine, placed on probation or surrendering a license to resolve an administrative action. Involved also means being named as a party to an administrative or arbitration proceeding which is related to a professional or occupational license and/or having a license application denied or the act of withdrawing an application to avoid a denial. You may exclude terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee. If answered YES, attach a copy of the following documents: A. Written statement identifying the type of license and explaining the circumstances of each incident; B. Notice of Hearing or other document that states the charges and allegations; and C. Official document that demonstrates the resolution of the charges or any final judgment. (3) Has any demand been made or judgment rendered against the applicant or any of its owners, governing members and/or officers? Have any of the aforementioned parties ever been subject to a bankruptcy proceeding? If answered YES, submit the following: A. Statement summarizing the details of the indebtedness and arrangements for repayment. (4) Has the applicant or any of its owners, governing members and/or officers ever been notified by any jurisdiction to which you have applied of any delinquent tax obligation that is not the subject of a repayment agreement? If answered YES, submit the following: A. Type of tax delinquency; and B. Jurisdiction(s) (5) Has the applicant or any of its owners, governing members and/or officers been party to or ever found liable in any lawsuit or arbitration proceeding involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty? If answered YES, attach a copy of the following documents: A. Written statement summarizing the details of each incident; B. Petition, complaint, or other document that commenced the lawsuit or arbitration; and C. Official document that demonstrates the resolution of the charges or any final judgment. (6) Has the applicant or any of its owners, governing members and/or officers ever violated any state or federal debt collection law? Have any of the aforementioned parties ever been convicted of a felony involving moral turpitude? If answered YES, attach a copy of the following documents: A. Written statement summarizing the details of each incident; B. Written explanation why you feel this incident should not prevent you from receiving an insurance license; and C. Official copies of all relevant documents.

6 6 Section 3.2 ~ Ethical Disclosures (continued) Provide an answer to all questions. Explanations are required for any question answered YES. (7) Has the applicant or any of its owners, governing members, officers and/or attorneys hired to collect debts/ receivables owned by the applicant ever been named as defendants in a lawsuit alleging violations of Article 70, Chapter 58 of the North Carolina General Statutes or any other state or federal debt collection law? If answered YES, attach a copy of the following documents: A. All complaints, answers, and responses to requests for admissions filed in such actions; and B. All final orders, judgments, and written settlement agreements in such actions. (8) Have any debtors in North Carolina or any other state ever asserted a counterclaim against the applicant or any of its owners, governing members, officers and/or attorneys hired to collect debts/receivables owned by the applicant for violating Article 70, Chapter 58 of the North Carolina General Statutes or any other state or federal debt collection law? If answered YES, attach a copy of the following documents: A. List both the State and statute(s) which the applicant and/or its attorneys allegedly violated and describe the nature of the alleged violations; B. Indicate whether or not any debtor ever prevailed on such counterclaim and attach a copy of all orders, judgments, and other documents showing that the debtor(s) prevailed on the counterclaim(s); C. Indicate if the applicant and/or its attorneys ever resolved any counterclaim by settlement with any debtor and attach a copy of all settlement documents showing how the counterclaim was resolved. (9) Has the applicant or any of its owners, governing members, officers and/or attorneys hired to collect debts/ receivables owned by the applicant ever been named as defendants in a lawsuit alleging violations of any state or federal unfair trade practice law? If answered YES, attach a copy of the following documents: A. All complaints, answers, and responses to requests for admissions filed in such actions; and B. All final orders, judgments, and written settlement agreements in such actions. (10) Have any debtors in North Carolina or any other state ever asserted a counterclaim against the applicant or any of its owners, governing members, officers and/or attorneys hired to collect debts/receivables owned by the applicant for violations of any state or federal unfair trade practice law? If answered YES, attach a copy of the following documents: A. List both the State and statute(s) which the applicant and/or its attorneys allegedly violated and describe the nature of the alleged violations; B. Indicate whether or not any debtor ever prevailed on such counterclaim and attach a copy of all orders, judgments, and other documents showing that the debtor(s) prevailed on the counterclaim(s); and C. Indicate if the applicant and/or its attorneys ever resolved any counterclaim by settlement with any debtor attach a copy of all settlement documents showing how the counterclaim was resolved.

7 7 SECTION 4: Collection Activities Section 4.1 ~ Collection Agency Type Select the category type that best describes the applicant s collection activities. [ ] Regular (a) An entity or person which procures a listing of delinquent debtors from any creditor, that sells the listing or otherwise receives any fee or benefit from collections made on the listing. (b) An entity or person which attempts to or does transfer or sell to any person not holding the permit prescribed by NCGS any system or series of letters or forms for use in the collection of delinquent accounts or claims which by direct assertion or by implication indicate that the claim or account is being asserted or collected by any person, firm, corporation, or association other than the creditor or owner of the claim or demand. (c) An in-house collection agency, whereby a person, firm, corporation, or association sets up a collection service for its own business and the agency has a name other than that of the business. [ ] Debt Buyer An entity or person who is engaged in the business of purchasing delinquent or charged-off consumer loans, credit accounts, or other delinquent consumer debt for collection purposes, whether it collects the debt itself, or hires a third party for collection or an attorney-at-law for litigation in order to collect such debt. Section 4.2 ~ Collection Telephone Numbers Provide all telephone numbers that will be used in the engagement of collection activities. ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) IF N/A: [ ] I (We) certify that the applicant does not and will NOT make collection calls to debtors in North Carolina. INITIALS: Section 4.3 ~ Collection Methods/Processes As required by NCGS (g) attach a sworn statement by an appropriate officer, partner or individual proprietor of the collection methods that will be used in collection activities within the state of North Carolina. Include a scripted dialogue, flowcharts/diagrams, office hours, as well as any other relevant information as it pertains to debt collection. Section 4.4 ~ Correspondence to Debtors NC collection agency licenses cannot be shared amongst offices, agencies or branches. Each location is required to have a separate license. Additionally, in accordance with the requirements of NCGS , all collection correspondence to must contain the following: (a) Legal & DBA/Trade (c) Address for Payment Acceptance (e) Placeholder for NC Permit Number (b) Agency Physical Address (d) Payment Receipt (NCGS ) [ ] I (We) certify that the compliance requirements of NCGS have been read and are understood. Accordingly, we WILL send correspondence to debtors in North Carolina. Attach samples of all correspondence. [ ] I (We) certify that the compliance requirements of NCGS have been read and are understood. Accordingly, we will NOT send correspondence to debtors in North Carolina. INITIALS:

8 8 Section 4.5 ~ Records Retention Location Provide the physical address of the location where North Carolina collection records will be available for inspection by the Commissioner of Insurance in accordance with NCGS Entities with multiple locations licensed in NC may use one (1) centralized storage location. Business : SECTION 5: Financial/Banking Information Bank (US banks only): Section 5.1 ~ Trust Account NCGS (a) requires each permit holder which receives payments from debtors to which the debtors creditors are entitled to maintain a separate trust account in any bank located in North Carolina or any other bank approved by the Commissioner for deposit of all moneys due or owed to all collection creditors or forwarders. Such funds shall be deposited in the trust account no later than two banking days after receipt. The funds shall remain in the trust account until remitted to the creditor or forwarder, and shall not be commingled with any operating funds. The trust account shall only be used for the purpose of: (1) remitting to collection creditors or forwarders the proceeds to which they are entitled; (2) remitting to the collection agency the commission that is due the collection agency; (3) reimbursing consumers for overpayments; and (4) making adjustments to the trust account balance for bank service charges. NCGS (c) further requires each permit holder located outside this State to deposit in a separate trust account, designated for its North Carolina creditors, funds to pay all monies due or owing all collection creditors or forwarders located within this State. For account verification purposes, attach a copy of the most recent trust account bank statement used for collection activity and, if required, the most recent trust account bank statement used for North Carolina creditors. Telephone Number: Trust Account Number: Section 5.2 ~ Request for Trust Account Exemption I (We) have read and understand the compliance requirements of NCGS , and accordingly request an exemption from maintaining a trust account. I (We) utilize collection methods that does not include the receipt of payments from debtors for the following reasons: Check all that apply: [ ] Payments are made directly to creditors [ ] We do not collect payments from debtors [ ] I (We) only negotiate debt payments [ ] Other (specify) Section 5.3 ~ Balance Sheet Attach a balance sheet certified true and correct by an authorized representative of the applicant. The balance sheet should reflect a positive net worth/equity of $5,000 or more and include activity as of the last day of the month just prior to submission of this application. Section 5.4 ~ Surety Bond Requirement & Power of Attorney Effective immediately, the Department will no longer accept use of one combined form for the bonds required by N.C.G.S (a) and (c). Instead, all applicants for initial and renewal permits will be required to submit the bond required by G.S (a). Foreign and alien applicants for initial and renewal permits will also be required to submit an additional bond required by G.S (c). Both bonds should be maintained in force during the entire permit period. The annual permit cycle is July 1st thru June 30th all surety bonds should follow that timeline, regardless of the initial start date. Refer to the Department s website for updated versions of the collection agency surety bonds.

9 9 SECTION 6: Attestations The undersigned, as Owners, Governing Members and/or Officers of the applicant (collection agency), hereby certifies under penalty of perjury, that: 1. All answers, statements, and supplementary materials supplied in and with this application are accurate, complete and true. I (We) agree that any permit issued shall be issued in express reliance thereupon. 2. The collection agency applicant grants permission to the NC Commissioner of Insurance to verify any information supplied with any federal, state, or local government agency, current or former employer and/or company. 3. I (We) hereby designate the NC Commissioner of Insurance to be its agent for service of process regarding all legal matters in the respective jurisdiction and agree that service upon the Commissioner is of the same legal force and validity as personal service upon the collection agency. 4. I (We) can confirm that this collection agency applicant will authorize the reimbursement to the NC Commissioner of Insurance, expenses incurred by the Commissioner in conducting routine examinations, audits, and investigating written complaints against the collection agency or its employees. Payment will be made to the North Carolina Department of Insurance within 30 days of the notification of the examination costs and expenses. (Foreign/Alien applicants only) 5. I (We) authorize the NC Department of Insurance to give any information they may have to any federal, state or municipal agency, or any other organization, and I (We) release the Department of Insurance and any person acting on their behalf from any and all liability of whatever nature by reason of furnishing such information. 6. I (We) acknowledge that neither the applicant, nor anyone affiliated with its businesses, has directly or indirectly violated any of the laws or regulations governing debt collections in North Carolina or any other State, except as otherwise stated herein. 7. I (We) can confirm that there are no unsatisfied judgments that are not currently the subject of litigation against the applicant, any of its owners, governing members, or officers. 8. I (We) acknowledge that I (we) have read the collection agency laws and regulations of North Carolina General Statutes, Chapter 58, Article 70, regarding debt collections and other collection activity to which I (we) am (are) applying for licensure/permit. 9. I (We) can confirm that the financial liquidity of the applicant is now, and will be continuously maintained in such a condition as to be immediately able to pay all current obligations of the collection agency and, in due course, to pay all long term obligations. 10. I (We) am (are) aware of the responsibility to annually renew the North Carolina collection agency license/permit, before June 30th, in order to continue as a legally licensed North Carolina collection agency. I (WE) HEREBY CERTIFY that on this day of, 20, the undersigned has executed the foregoing application, being duly authorized to do so. The information and statements contained in this application, including all documents attached and other information filed thereafter as a part of this application, are correct, true, accurate, and complete. The authorized representative knows and understands that if the Applicant/Company has knowingly made a false or misleading statement of material fact in this application or in any of its supporting documentation, then the application for collection agency licensure will be denied and the Applicant/ Company, its Owners, Governing Members and/or Officers may be subject to criminal penalties under North Carolina Regulatory Law. of Applicant/Company: Signature of Authorized Representative: Print & :

10 10 MANDATORY ATTACHMENTS (All Applications) The documents listed below are a mandatory component for all collection agency licensure applications. It is critical that they are included as a part of the applicant s submission. Personal Questionnaires (DOI-5C) for all owners, governing members, and officers (Listed in Sections 2.1/2.2/2.3) Board Resolution/Owner Authorization to apply for a NC collection agency permit (Listed in Sections 2.6) Corporation Formation Documents (as applicable): Articles of Incorporation (notarized and/or certified by State) Corporation Formation Documents (as applicable): By-Laws (notarized and/or certified by State) LLC Formation Documents (as applicable): Articles of Organization (notarized and/or certified by State) LLC Formation Documents (as applicable): Operating Agreement (notarized and/or certified by State) Partnership Formation Documents (as applicable): Partnership Agreement (notarized and/or certified by State) Certificate of Authority from NC Secretary of State (foreign & alien applicants only) Collection Methods/Processes (Listed in Section 4.3) Correspondence to Debtors (Listed in Section 4.4) Trust Account Bank Statement (Listed in Section 5.1) Balance Sheet dated as of end of last month (Listed in Section 5.3) Original, Notarized Surety Bonds & Power of Attorney (Listed in Section 5.4 w/revision date 04/03/2013) (Selected Applications) The documents listed below are a mandatory, but are contingent on the answers provided by the applicant. If these items do not apply to your application, please disregard. Business Relationships Flowchart/Diagram (Listed in Sections 2.4) Parent Company Audited Financial Statements (Listed in Section 2.4) Parent Company Guarantee of Applicant s Financial Performance (Listed in Sections 2.4) Lawsuit Final Judgments/Charging Documents/Settlement Agreements (Listed in Section 3.2) DBA/Trade Registration within NC Counties (where business will be conducted)

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