| Part One |
- Licensee’s name: ___________________________________________
- Licensee’s Federal Employer Identification Number: ______________
- Name and address of principal contact person:
Name: ________________________________________________
Street address: __________________________________________
City and state: __________________________________________
Telephone number: ______________________________
Fax number: ___________________________________
E-Mail: _______________________________________
- Licensee’s principal business office:
Street address: __________________________________________
City and state: __________________________________________
Telephone number: ______________________________
Fax number: ___________________________________
- Address at which licensee keeps its books and records (if different from answer to Question 4).
Street address: __________________________________________
City and state: __________________________________________
Telephone number: ______________________________
Fax number: ___________________________________
- Licensee is a(n): (Check appropriate classification)
Individual
Association
Corporation
Partnership
Joint Stock Association
- Type of money transmission activity conducted (mark all that apply):
Checks
Drafts
Money Orders
Stored Value
Travelers Checks
Wire Transfers
Other (explain): _________________________
- Money transmission sales are conducted through (mark all that apply):
Company Owned Outlets
Independent Authorized Delegates
Subsidiaries or Affiliates; and/or
Other (explain): ________________________________
- Submit the complete name and address of each location in the state from which the licensee or its authorized delegates conducts money transmission sales.
State the number of sales locations in this state: ___________.
| Part Two |
INSTRUCTIONS: Please check either “yes” or “no” in response to the following questions regarding changes since the last application or renewal. IF THERE HAVE BEEN ANY CHANGES, PLEASE PROVIDE THE REQUESTED INFORMATION (Note that a response to the following does not constitute compliance with any separate statutory notice or reporting requirement):
- Have there been any changes in principal officers, directors, partners, or individuals with a 25% or more ownership interest in the licensee, since the previous renewal?
Yes No
If yes, please explain changes on a separate sheet, and include the name, title, business address and percentage ownership of each person who has acquired an ownership interest or become an officer or director of the licensee.
- Has the licensee had its license suspended, revoked or renewal refused in any other state since the last application or renewal?
Yes No
If yes, please explain on a separate sheet.
- Has the licensee been subject to any enforcement actions by its licensing authority in any other state since the last application or renewal?
Yes No
If yes, please explain on a separate sheet.
- Has there been any material litigation involving the licensee initiated since the last application or renewal? Material litigation means litigation that, according to generally accepted accounting principles, is deemed significant to any licensee’s financial health and would be required to be referenced in its annual audited financial statements, report to shareholders or similar documents.
Yes No
If yes, describe the proceedings on a separate sheet.
- Has there been any felony indictment or criminal conviction of any principal officer or partner of the licensee, or any individual with a 25% or more ownership interest in the licensee, since the last application or renewal?
Yes No
If yes, please explain on a separate sheet.
- Have there been any substantive changes to the form of instruments issued by the licensee since the last application or renewal, if not previously provided?
Yes No
If yes, please provide a specimen if not previously provided.
- Have there been any changes in the licensee’s principal clearing banks, clearing bank address or account number since the last application or renewal?
Yes No
If yes, please list the name, address, contact name and account number on a separate sheet.
- Have there been any material changes to the licensee’s authorized delegate contract since the last application or renewal?
Yes No
If yes, please provide a copy.
- Has there been any change to the licensee’s internal auditor(s) since the last application or renewal?
Yes No
If yes, please provide the new contact name and phone number on a separate sheet.
- Has the licensee, or any principal officer, director, partner, or individual with a 25% or more ownership interest in the licensee, filed a petition in bankruptcy or reorganization since the last application or renewal?
Yes No
If yes, please describe the proceedings on a separate sheet, and provide a copy of the petition and a copy of the discharge, if applicable.
| Part Three |
- Submit the following:
A. The most recent audited financial statements of the licensee, including balance sheet, statement of income, statement of stockholder's equity and statement of cash flow for the preceding year, prepared by an independent certified public accountant, if not previously provided.
B. The most recent unaudited interim financial statements prepared for the licensee, dated no more than 120 days from the date of this application, if not previously provided. C. - In the space provided below, state:
- (1) The total dollar amount of the licensee's outstanding instruments and transmissions in this state
- (a) as of the date of the most recent audited financial statement, and
- (b) as of the date of the interim financial statement filed in accordance with prior request 1(B).
- (2) The total dollar amount of the licensee's outstanding instruments and transmissions in the U.S.A.
- (a) as of the date of the most recent audited financial statement, and
- (b) as of the date of the unaudited interim financial statement filed in accordance with prior request 1(B).
Outstandings as of:
Date of
State of ______________
Total U.S.A.
Audited F/S
_____________
$__________________
$__________________
Interim F/S
_____________
$__________________
$__________________ - In the space below, provide the number and dollar amount of payment instruments sold/issued and money transmissions conducted by the licensee from ________________ through the close of business _________________ (12 month period):
Within the State
Total Within U.S.A.
Number _______________
_______________
Amount _______________
_______________ - If required by state law, submit a list of the licensee's permissible investments, and the book or market value of such investments:
(1) as of the date of the most recent audited financial statement, and
(2) as of the date of the unaudited interim financial statement filed in accordance with prior request 1(B).
- If audited financial statements are not provided, and if permissible investments are required by state law, the following is required:
A certification by an independent certified public accountant that the licensee's permissible investments, at all times possess a book or market value calculated in accordance with generally accepted accounting principles, of not less than the aggregate dollar amount of all outstanding payment instruments issued or sold by the licensee in the United States.
- Submit proof of surety required and/or a list of deposits and other obligations maintained in lieu of all or part of the corporate surety bond, as authorized by statutes. For each deposit, please designate the amount of each deposit, the financial institution in the state which is the depository, and the account number.
I certify that the foregoing responses are true, accurate and complete to the best of my knowledge and belief.
Dated:
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NAME OF LICENSEE (Corporation, Company, Partnership) By: ________________________________________ (Officer/Authorized Employee) (Title) (please print) ________________________________________ (Signature of Officer/Authorized Employee) |