Debt Management Service Provider Registration Application

By Leonard Rose,2014-04-30 20:28
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Debt Management Service Provider Registration ApplicationDebt,debt,DEBT

Oregon Department of Consumer and Business Services

    Division of Finance and Corporate Securities

    350 Winter St. NE, Rm. 410, Salem, Oregon 97301-3881

    Mailing address: P.O. Box 14480, Salem, OR 97309-0405

    503-378-4140 ; Fax: 503-947-7862


     1. Company information:


     Physical address:

     City: State: ZIP:

     Mailing address (if different):

     City: State: ZIP:

     Phone: Fax:

     Please check one: For profit Not-for-profit

     E-mail address: Web site address:

     2. List any assumed business names to be used by the debt management services provider.

     3. List name, address, and phone number of registered agent.



     City: State: ZIP:


    Submit a non-refundable application fee by sending a check - - Visa MasterCard Discover Phone: or money order in the amount of $350 payable to Oregon / Division of Finance and Corporate Securities. If paying by Credit card number Expiration date credit card, applicant must sign credit card information box. Mail application with payment to: Name of cardholder as shown on credit card DCBS Fiscal Services P.O. Box 14610 $ Salem, OR 97309-0405 Cardholder signature Amount

    Fiscal use only: Initial: 61220/1008 12104-0600

     440-4858 (12/09/COM) 1

     4. List bank accounts

     Operating account name: Account no.:

     Name of financial institution:


     City: State: ZIP:

     Client trust account name:

    If more than one client trust account is used, please provide a list that contains the name of the financial institution,

    address of the financial institution and the account numbers.

     Account no.:

     Name of financial institution (bank must have a branch in Oregon):


     City: State: ZIP:

     5. Please provide the following items:

    a) Financial statement that includes a profit & loss and balance sheet dated within the past 12 months.

    b) Copies of the debt management services contract or agreement to be signed by the consumer, a copy of the fee

    schedule, and voluntary contributions to be paid by the client.

    c) Copy of the disclosure form to be signed by the consumer that lists the maximum amount the debt management

    service provider may charge for services performed for the client. (The form must contain a space for the client to

    sign, indicating that the client has read and understands the information disclosed on the form.)

    d) Original or correct and true copy of the surety bond in the amount of $25,000, accompanied by Debt Management

    Service Provider Surety Bond Form 440-4858a (attached).

    e) Attorneys and CPAs must provide state license numbers.

    f) Business name and ID number, license number, registration number, etc., used for any activities you conduct in

    any other states.

    g) Sample budget analysis. (ORS 697.652(2))

    h) Organizational chart. Briefly describe control relationships, including percentage of interest. Attach separate


    i) Detailed description of the debt management service activities you plan to undertake in Oregon. (Attach a

    separate sheet.)

    j) Will the applicant engage in other business activities not regulated under the debt management services provider

    statutes? Yes No

    If yes, please describe:

     440-4858 (12/09/COM) 2

6. Please provide information for the following employees for a background check (ORS 697):

    a. Owner, officer

    b. Managers or supervisors of agency activities c. Any individual who acts as agent for the agency Fill in identifying information below. Indicate each individual’s function(s) with an (a), (b), or (c). Attach additional pages,

    as necessary.

    Driver license

    (state of issue, a, b, or c

    (see above) Legal name and residential address Date of birth number)

For each person listed above, submit a resume detailing past training and job experience.

    For each person listed above, provide a separate signed statement that identifies and describes in detail any situation in which any of the individuals, within the past five years, was subject to:

    1. A judgment in favor of another party.

    2. An arbitration award in favor of another party.

    3. An adverse final order from an administrative agency in any state

    4. Have the owners, agents, or anyone working for you been convicted of an offense involving fraud or deception?

     Yes No (If yes, attach a description of the circumstances of the conviction.)


    This form is executed on behalf of, and with the authority of, the applicant. The undersigned and applicant declare the

    information and statements contained in this application and enclosed with this application to be current, true, and complete. Date: Name of applicant:

    Signature: Name and title:

    Subscribed and sworn before me this day of , 20 .

    By (notary):

    My commission expires:

    County of:

    State of: (Seal)

     440-4858 (12/09/COM) 3

Oregon Department of Consumer and Business Services

    Division of Finance and Corporate Securities

    350 Winter St. NE, Rm. 410, Salem, Oregon 97301-3881

    Mailing address: P.O. Box 14480, Salem, OR 97309-0405

    503-378-4140 ; Fax: 503-947-7862



     Surety Bond No.:

    That (name), (address),

    as principal (licensee), and the (surety home address) (surety),

    a corporation duly organized and existing under the laws of and authorized to transact a

    surety business in Oregon, as surety, are held and firmly bound unto the state of Oregon, for the use of the state and any person who

    may have a cause of action against the principal, in the penal sum of $25,000, lawful money of the United States, for the payment of which we bind ourselves, our heirs, executors, administrators, successors, and assigns, jointly and severally, firmly by these presents.

    The condition of this obligation is such that the above-named principal has applied to the director of the Oregon Department of Consumer

    & Business Services (DCBS) for carrying on the business of a debt management service provider within the state of Oregon and is required by Oregon Revised Statute Chapter 697 to furnish a bond in the sum of $25,000 to cover the operation of the business during

    each biennial registration period.

    Now, therefore, the conditions of the foregoing obligation are that if said principal with regard to all work done by the principal, a debt

    management service provider, as defined in ORS 697, shall comply with all provisions of said statute and rules promulgated thereunder, shall pay all amounts that may be ordered by the director of DCBS against the principal by reason of failing to comply with ORS Chapter

    697 and rules promulgated thereunder, then this obligation shall be void. Otherwise it will remain in full force and effect.

    This bond is for the exclusive purpose of payment of final orders of the director of DCBS and court judgments filed with the director

    of DCBS in accordance with ORS Chapter 697.

    This bond may be canceled by the surety and the surety is relieved of further liability hereunder by giving 30 days written notice to the

    principal and to the director of DCBS.

    This bond shall be one continuing obligation, and the liability of the surety for the aggregate of any and all claims that may arise hereunder shall in no event exceed the amount of this bond. The surety shall give notice to the principal and to the director of DCBS

    upon any payment for a loss under this bond.

    This bond shall become effective on the day of , 20 .

    IN WITNESS WHEREOF, we have hereunto set our hands and seals at in the state of .

    SIGNED, sealed, and dated this day of , 20 .






    Title: (Seal)

     440-4858a (12/09/COM)

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