Fillable Printable Form 40495
Fillable Printable Form 40495
Form 40495
INFORMATION AND INSTRUCTIONS
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APPLICATION FOR COLLECTION
AGENCY LICENSE
State Form 40495 (R7 / 4-12)
Approved by State Board of Accounts, 2011
Indiana Code 25-11-1 et seq.
CONNIE LAWSON
INDIANA SECRETARY OF STATE
SECURITIES DIVISION
302 W. Washington Street, Rm. E111
Indianapolis, IN 46204
Telephone: (317) 232-6681
www.sos.IN.gov
Please read this application carefully.
The application must be legible.
To ensure continuous operation of a collection agency, please return the completed renewal application by the 1st of December of each renewal year.
Each out-of-state agency must include with this application a valid Collection Agency License from the Issuing home state or a statement your home
state does not require a license.
A check made payable to the Indiana Secretary of State must accompany the application. Cash will not be accepted. The application fee is $100.00 plus
an additional $30.00 with each branch office application. Registration must be renewed every two (2) years.
The applicant must obtain a bond from a surety company authorized to do business in Indiana. The bond must be filed with this application. Each office
wishing to collect in Indiana must provide a Collection Agency Application and a $5000.00 bond.
If the applicant is a Partnership or a L.L.P. (Limited Liability Partnership), please include with this application the name of each partner and the
residential address of at least one partner.
If the applicant is a L.L.C. (Limited Liability Company), please include with this application the date and place of organization of the L.L.C., the names
of each manager and member of the L.L.C., and the residential address of at least one manager of the L.L.C.
If the applicant is a Corporation, please include with this application the date and place of incorporation, the names of all officers of the corporation,
and the residential address of at least one of the officers of the corporation.
Individual Partnership Limited Liability Partnership (L.L.P.) Limited Liability Company (L.L.C.) Corporation
Type of company (check one)
Name of company or, if the applicant is an individual, name of individual
Business address (number and street, city, state, and ZIP code)
County
Doing business as, if applicable Fax number Telephone number (including any 800 number)
List any offices to be located in Indiana.
County
County
County
County
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Main office filing fee: $100.00
Branch office filing fee: $30.00
Filing fees should be made
payable to Secretary of State.
Address (number and street, city, state, and ZIP code)
Address (number and street, city, state, and ZIP code)
Address (number and street, city, state, and ZIP code)
Address (number and street, city, state, and ZIP code)
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Type of application (check one)
Original Application Renewal application Main office Branch office
Type of office (check one)
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Name of principal
Home address (number and street, city, state, and ZIP code)
Name of person to whom correspondence may be addressed if different from principal
Business address (number and street, city, state, and ZIP code)
Telephone number
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E-mail address
Telephone number
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E-mail address
Reset Form
AFFIDAVIT
I, ______________________________________________, as principal of the foregoing business entity, do solemnly swear that:
(1) every partner, member, manager, or officer of this collection agency business, including myself, is:
(a) a citizen of the United States of America;
(b) of good moral character;
(c) not less than eighteen (18) years of age;
(d) not a person who has ever defaulted in the payment of money collected or received for another:
(e) not a former licensee in this state whose license has been suspended or revoked and not subsequently reinstated.
I further swear and affirm that the foregoing answers and statements in this application and any related forms were made by me and that they are true
and accurate to the best of my knowledge and belief.
NOTARY CERTIFICATE
I, ____________________________________________ (principal), having been duly sworn, say that I am the above-named principal and that the
application is true to the best of my knowledge and belief.
Printed or typed name of applicant
STATE OF ____________________________________
COUNTY OF __________________________________
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Printed or typed name of Notary Public
Date commission expires (month, day, year)
County of residence
Signature of applicant
Date signed and witnessed by Notary Public (month, day, year)
Signature of Notary Public
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Is applicant a resident of the State of Indiana? Yes No
(If not, applicant must appoint a resident agent for service of process and agree that service upon such agent will be valid service upon the
applicant. The statement appointing the agent must accompany this application and must include the address and telephone number of the agent.)
Is the applicant a judge or law enforcement officer? Yes No
Has any member, partner or officer of this business been convicted of a misdemeanor or felony within the past ten (10) years? YesNo
Is any member, partner, or officer of this business a law enforcement officer or judge? Yes No
