Annual Report To The Division Of Financial Institutions Page 2

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ANNUAL REPORT TO THE DIVISION OF FINANCIAL INSTITUTIONS
FOR THE YEAR ENDED DECEMBER 31, 20__
To Be Filed On Or Before MARCH 1ST
By All Companies Engaged In Business Under The Consumer Installment Loan
Act (CILA) In The State Of Illinois. Include Data On Any Licenses Surrendered That Were Active In Liquidating Receivables
During The Year.
We encourage you to use the automated data entry form that is available on our website, , or on disk by calling
217-782-3704. The automated form is very easy to use, will save you lots of time, and will reduce the chance of you submitting a
report with errors.
READ THE INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS REPORT.
REPORTING ENTITY
1. Name of Licensee
License Number
FEIN Number
2. Is this a Consolidated Report?
Number of Licensed Offices Included In This Report:
Number of Limited Purpose Branches Included In This Report:
3. Check One: Corporation
Partnership
Association
Sole Proprietorship
LLC
4. Place of Business
(City, State)
(Telephone)
5. Basis of Computing Interest Charges: (check all that apply)
Simple Interest
Precomputation
6. Number of Employees Within The State At Year End:
Full Time
Part Time
*E-MAIL ADDRESS: ___________________________________________________
SCHEDULE A
PROFIT PERCENTAGES
(ROUND OFF ALL CURRENCY TO NEAREST DOLLAR.)
CILA
OTHER BUSINESS
Under $25,000
AUTHORIZATION
TOTAL
S
RATE OF RETURN
7. Average Net Receivables
Outstanding
8. Net Income (Must Match Item 38 in Schedule B)
9. Rate of Return (Line 8 divided by Line 7)
ANALYSIS OF CHARGES
10. Charges Collected/Earned (must match schedule B)
11. Average Monthly Rate Collected
ANALYSIS OF EXPENSE PER ACCOUNT
12. Average Number of Accounts Outstanding
13. Total Expenses (Must Match Item 37 in Schedule B)
13a.Average Monthly Expense Per Account
2

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