Illinois Payday Lender License Application CheckList

1. Application Form
2. A copy of all organization documents is required to be filed with the Illinois Secretary of State and a copy of the filing of assumed business name with the appropriate County Clerk’s office if a sole proprietorship.
3. “Supplemental Application” as provided in the application packet and credit report of:
   1. the proprietor, if the applicant is an individual
   2. every partner, if the applicant is a partnership
   3. the President, Secretary, Executive and Senior Vice Presidents, Directors, and individuals owning more than 25% of the corporate stock, if the applicant is a corporation; and
   4. the manager, if the applicant is a limited liability company
4. Most recent year-end and quarter-end financial statements, or opening statements for new corporations, completed according to Generally Accepted Accounting Principals and certified by the original signature of the applicant, President, or manager of limited liability, or partner thereof. The balance sheet must contain only business-related items and demonstrate a net equity (total assets minus total liabilities) of $30,000.
5. Original $50,000 Surety Bond in favor of the Director of the Division of Financial Institutions, signed and sealed by the applicant and Attorney-in-Fact of the bonding company.
6. Appointment of Attorney-in-Fact for Service of Process
7. Photographs of both the inside and outside of the proposed location
8. Business Plan detailing the nature, amount, and term of loans to be made and types of security that will be taken
9. A list of all states where the applicant is licensed to issue Payday Loans. If the said license has been withdrawn, refused, canceled, or suspended in any other state, please state the specifics surrounding this event
10. Information Form as provided in the application packet
11. A check in the amount of $1000 forwarded to the Illinois Department of Financial and Professional Regulation to serve as a license fee. Fees are not refundable.
12. A request for authorization of any other business to be conducted at the licensed location
    1. If requesting an Other Business Authorization, please forward a separate check to the Illinois Department of Financial and Professional Regulation in the amount of $100 per Other Business Authorization (OBA) requested. NOTE: Only one OBA is issued to a company to cover all licensed locations. This fee is non-refundable.

 

Please return the completed application and related fees to the address list below:

Illinois Department of Financial & Professional Regulation

Division of Financial Institutions

Consumer Credit Section

100 W. Randolph St. Suite 9-100

Chicago, IL 60601

 

Office Use Only Log No.___________ Check #___________ Fee Slip__________

STATE OF ILLINOIS

DEPARTMENT OF FINANCIAL & PROFESSIONAL REGULATION

DIVISION OF FINANCIAL INSTITUTIONS

APPLICATION FOR PAYDAY LENDER LICENSE

PAYDAY LOAN REFORM ACT

Application is hereby made to the Director of Financial Institutions for a license to

engage in the business under the provisions of the Illinois Payday Loan Reform Act.

 

1. Full Name of Applicant:_______________________________________________

2. Proposed Licensed Location:________________________________________          

(Address)                                                                                            

(City)               (County)                      (State)            (Zip Code)

 

3. Corporate Address:__________________________________________________________________

                                                                                          

(City)                              (State)                           (Zip Code)

 

4. ( )                                              5.  (    )_______________________________                            

Telephone #                                              Fax #                                  

Contact Person                                           Federal Employer I.D. #

 

8. Type of Ownership: Sole Proprietorship      , Partnership      ,  Corporation      , Limited Liability Company      ,

 

Other____________________________________________________________________

9. If the entity is a corporation, State of Incorporation:______________________________________

10. Is applicant licensed to issue Payday Loans in any other State or Territory of the S.? ___________________

IF Yes, provide a list of the States.

11. At any time has the applicant entity listed above had its license cancelled or suspended in any other State or Territory of the S.? _____________________

If Yes, provide full details on a separate sheet.

12. At any time has the applicant ever had an application for a license to issue Payday Loans withdrawn or refused in any other State or Territory of the S.? ________________

If Yes, provide full details on a separate sheet.                              

If the entity is a foreign corporation, the date, and number of Charter in Illinois:

_________________                               

Date                            Number

Page 1 of 2

14.______  The Proposed site is not within one mile of a horse race track subject to the Illinois Horse Racing Act of 1975, within one mile of a facility at which gambling is conducted under the Riverboat Gambling Act, within one mile of the location at which a riverboat subject to the Riverboat Gambling Act docks, or within one mile of any State of Illinois or the United States military base or naval installation.

OR

______  The location was already in existence as a payday loan business as of June 1, 2005.

15. Does the applicant/entity maintain any other licenses issued by the Department of

Financial and Professional Regulation? ____________

If YES, please list type of license and license number:                              

16. Describe any other business that will be conducted at this location other than the business of making loans under the Payday Loan Reform Act.

                                                                                                                                     under penalties of perjury, I declare that I have examined the application and all supporting documents submitted by me in connection therewith, and to the best of my knowledge, they are true, correct, and complete.

                                         __________________                           

(Signature of Applicant)                 Date________

STATE OF ILLINOIS

DEPARTMENT OF FINANCIAL & PROFESSIONAL REGULATION

DIVISION OF FINANCIAL INSTITUTIONS

SUPPLEMENTAL APPLICATION PAYDAY LENDER LICENSE

 

All answers must be TYPED or legibly PRINTED.  All questions must be answered.

 

1. Individual’s Name:_______________________________________________________________                                                               

(First)                   (Middle)          (Last)

 

2. Corporate Title:_____________________________________                                    

 

3. Percentage of Ownership:_____________          

 

4. Date of Birth:_______________________                    

 

5. Social Security Number:__________________________________________________________                             

 

6. Business Address:________________________________________________________________                                                               

 

7. Resident Address:________________________________________________________________                                                               

 

8. Telephone Number:________________________________________________________________                                                               

 

9. Business Experience for past ten (10) years in descending chronological

Order:  (A copy of a resume for the same period of time may be substituted

to satisfy this requirement.)

   Years______________________________________________________________________________                                                                             

 

From     To     Company Name:_________________________________________________________                                                       

 

Company Address:______________________________________________________________________                                                                    

 

Position Held:________________________________________________________________________                                                                      

 

Principal Duties:_____________________________________________________________________                                                                   

 

 

   Years______________________________________________________________________________                                                                             

 

From     To     Company Name:_________________________________________________________                                                       

 

Company Address:______________________________________________________________________                                                                    

 

Position Held:________________________________________________________________________

 

Principal Duties:_____________________________________________________________________

 

 

   Years______________________________________________________________________________

 

From     To     Company Name:_________________________________________________________

 

Company Address:______________________________________________________________________

 

Position Held:________________________________________________________________________

 

Principal Duties:_____________________________________________________________________

 

10. In the past 10 years, have you ever been convicted of a felony?

 

Yes                              No_____    

 

If yes, provide on a separate sheet full details, including a summary, the

the court, the presiding judge(s), and the title and document number.

11. In the past 10 years, have you been a party to any material litigation?

Yes                                   No_____

If yes, provide on a separate sheet full details, including a summary, the

court, presiding judge(s) and the title and document number.

Under penalties of perjury, I declare that I have examined the application and all supporting documents submitted by me in connection therwith, and to the best of my knowledge they are true, correct and complete.

                                         __________________                           

(Signature of Applicant)                  Date

Page 2 of 2

STATE OF ILLINOIS

DEPARTMENT OF Financial & PROFESSIONAL REGULATION

DIVISION OF FINANCIAL INSTITUTIONS

LICENSEE BOND

Payday Loan Reform Act 

KNOW ALL MEN BY THESE PRESENTS, That_____________________________________________________________

Corporate or Company Name

 

___________________________________________________________________________________

Street Address                                   City/State

 

and,________________________________________________________________________________

as surety, are held and firmly bound unto the Division of Financial Institutions, for the use of the State and of any person or persons who may have a cause of action against the obligors of this instrument, under the provisions of the Act hereinafter described, in the penal sum of                                                            for the period from this date_________________________ to December 31, ________, for the payment of which, well and truly to be made, we bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents.

Witness our hands and seals this               day of                     , A.D.______

The condition of the above obligation is such that the above                          

___________________________________________________________________________________

Corporate or Company Name has applied for a license for the term ending December 31, 20____, to transact the business of making loans in accordance with the provisions of the Illinois Payday Loan Reform Act.

 

Now, if the said______________________________________________________________________

Corporate or Company Name

 

shall, upon issuance of said license as aforesaid, faithfully conform to and abide by each and every provision of said Act and of all rules, regulations and directions lawfully made by the Director of Financial Institutions, and will pay to the State and to any person or persons from said obligors, under and by virtue of the provisions of said Act, then this obligation to be void, otherwise to remain in full force and effect.

___________________________________

Corporate or Company Name

 

By_________________________________

President, Owner or Partner

 

By_________________________________

Secretary, Owner or Partner

 

 __________________________________

Surety or Bonding Company

 

By_________________________________

Illinois Attorney-in-Fact

 

(Attach Power of Attorney)

State of Illinois

Department of Financial & PROFESSIONAL REGULATION

DIVISION OF FINANCIAL INSTITUTIONS   appointment of attorney-in-fact for service of process know all men by these presents:

that_____________________________________________________________________________________________

Corporate or Company Name

 

_________________________________________________________________________________________________

Street                                City

 

                          ____                      does hereby appoint the

County                      State

 

incumbent Director of the Division of Financial Institutions of the State of Illinois and his/her successors in office, or any official who shall hereafter be charged with the administration of the Payday Loan Reform Act, its attorney-in-fact upon whom all processes of law against it arising out of any transaction under the Payday Loan Reform Act may be served.  The appointment of the Director of Financial Institutions as attorney-in-fact is conditional upon the issuing of a license to conduct a business of making loans under the Payday Loan Reform Act and in the event that a license is not granted, this appointment shall remain in full force and effect and may not be revoked except by consent of the Director of Financial Institutions.  In the event that the license of said applicant is revoked, surrendered or otherwise terminated, the appointment of the Director of Financial Institutions as attorney-in-fact to accept service of process shall continue until such time as all matters arising out of the conduct of said licensee’s business in this state shall have been concluded.

 

IN WITNESS WHEREOF, the applicant has set his hand and seal in the City of                                            State of                                 ,

 

On                                                                             20    

(CORPORATE SEAL)    By__________________________________

(President, Owner, Partner)

 

By__________________________________

(President, Owner, Partner)

 

                 

CORP. FILE NUMBER                                          

IF OUT OF STATE

                                

 

Subscribed and sworn to before me this           day of                       20_____

 

Notary Public                        My Commission Expires_______________________

 

 

NOTARY SEAL

 

 

 

 

 

 

INFORMATION FORM

 

 

 

1. Name, Title, Percent of Stock Ownership and Resident Address of Every officer

of the Licensed Entity.

 

1. _________________________________________________________________________

(Name)                   (Title)                  (Percent of Stock)

 

_________________________________________________________________________  

(Address)                        (City)         (State)               (Zip Code)

 

1. _________________________________________________________________________

(Name)                   (Title)                  (Percent of Stock)

 

_________________________________________________________________________                                                                     

(Address)                        (City)         (State)               (Zip Code)

 

1. _________________________________________________________________________                                                                             

(Name)                   (Title)                  (Percent of Stock)

 

_________________________________________________________________________                                                                             

(Address)                        (City)         (State)               (Zip Code)

 

(If more space is required attach a separate sheet)

 

1. Name, Title, Percentage of Ownership and Resident Address of Each Director of

the Licensed Entity.

 

1. _________________________________________________________________________                                                                             

(Name)                   (Title)                  (Percent of Stock)

 

_________________________________________________________________________                                                                             

(Address)                        (City)         (State)               (Zip Code)

 

1. _________________________________________________________________________                                            

(Name)                   (Title)                  (Percent of Stock)

 

_________________________________________________________________________                                                                           

(Address)                        (City)         (State)               (Zip Code)

 

1. _________________________________________________________________________

(Name)                   (Title)                  (Percent of Stock)

 

_________________________________________________________________________                                                                           

(Address)                        (City)         (State)               (Zip Code)

 

(If more space is required attach a separate sheet)

 

III.  Name, Percent of Ownership and Resident Address of Each Stockholder Owning

10% or More of Capital Stock or Any Owner/Partner of the Licensed Entity who

is Not Listed Above.

 

1. _________________________________________________________________________                                                                             

(Name)                                    (Percent of Stock/Ownership)

 

_________________________________________________________________________                                                                            

(Address)                        (City)         (State)               (Zip Code)

 

1. _________________________________________________________________________

(Name)                                    (Percent of Stock/Ownership)

 

_________________________________________________________________________                                                                           

(Address)                        (City)         (State)               (Zip Code)

 

1. _________________________________________________________________________                                                                             

(Name)                                    (Percent of Stock/Ownership)

 

_________________________________________________________________________                                                                            

(Address)                        (City)         (State)               (Zip Code)

 

(If more space is required attach a separate sheet)

 

 

The Percentage of Ownership from Section I, II and III Must Total 100%