Illinois Administrative Code › Title 14 - COMMERCE › Part 177 - CREDIT SERVICES ORGANIZATIONS › ILLUSTRATION A - Services Organization Registration Statement

Current through Register Vol. 48, No. 28, July 12, 2024
STATE OF ILLINOIS
CREDIT SERVICES ORGANIZATION
REGISTRATION STATEMENT
($100 Filing Fee)
This registration statement, along with a $100 filing fee and a
				$100,000 surety bond are to be filed with the Secretary of State, Index
				Department, 111 East Monroe Street, Springfield, IL 62756.
When a change in the information contained in this statement
				occurs the credit services organization is required to file an amended
				statement within 90 days. There is no fee for filing amended statements.
A credit services organization is required to continuously
				maintain a $100,000 surety bond if that credit services organization charges or
				receives any money or other valuable consideration prior to full and complete
				performance of the services the credit services organization has agreed to
				perform. A bond shall also be maintained for a period of 2 years after the date
				that the organization ceases operations.
A file-stamped copy of this statement will be returned to the
				credit services organization who must maintain the copy in their files and
				allow a buyer to inspect the registration statement.
1. Name and address of the credit services
			 organization.
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
2. Name and address of the registered agent
			 or individual authorized to accept service of process on behalf of the credit
			 services organization.
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
3. Name and address of any and all persons
			 who directly or indirectly own or control 10 percent or more of the outstanding
			 shares of stock in the credit services organization. (If additional space is
			 needed, attach a listing)
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
4. If any, the bond number, name and location
			 of the surety company issuing a $100,000 surety bond as required by the Credit
			 Services Organizations Act.
Bond number:
				________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
5.
(A) Has
			 there been any litigation or unresolved complaint filed with a governmental
			 authority of this State, any other state or the United States relating to the
			 operation of this Credit Services Organization?No
			 Yes
If answer is yes, you must attach a full and complete
				disclosure.
(B) If there has
			 been no litigation or unresolved complaint filed, the following statement must
			 be completed and notarized.
I,
________________________,
___________________
name
official capacity
of
____________________________________________
name of credit services
						  organization
do hereby affirm that there has been no litigation or
				unresolved complaint filed with a governmental authority of this State, any
				other State or the United States relating to the operation of this credit
				services organization.
_____________________________
signature
Subscribed and affirmed to before me on
_____________, 19_____________
_____________________________
signature of notary public
(seal)