Form Hcc 90-01 - Health Care Card Suppliers Application Form Of Annual Notice
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1
2
3
4All information on the health care card
kansas secretary of state
HCC
suppliers form must be complete and
Health Care Card Suppliers
accompanied by the correct filing fee or the
Application of Annual Notice
90-01
document will not be accepted for filing.
Instructions
Save time and money by filing your forms
Kansas Office of the Secretary of State:
online at There, you can
also stay up-to-date on your organization’s
Memorial Hall, 1st Floor
(785) 296-4564
120 S.W. 10th Avenue
kssos@sos.ks.gov
status, annual report due date, and contact
addresses.
Topeka, KS 66612-1594
Filing fee
The filing fee for this document is $250. Mail completed form HCC (Health Care Card
o
Suppliers Application of Annual Notice) along with surety bond form SB (Health Care Card
Supplier Bond).
Payment
Please enclose a check or money order payable to the Secretary of State. Forms received
o
without the appropriate fee will not be accepted for filing. Please do not send cash. NOTICE:
There is a $25 service fee for all checks returned by your financial institution. Also, to
expedite processing, please do not use staples on your documents or to attach checks.
Renewal date
The applicant must maintain a surety bond in the amount of $50,000. The surety bond Form
o
SB shall be submitted to the Secretary of State along with the annual notice Form HCC and is
subject to the approval of the Kansas Attorney General. This office will forward the bond to the
Attorney General prior to filing. The month in which the supplier files its first annual notice with
the Secretary of State is the month in which its filings are due annually thereafter, if the filing
remains current and in compliance.
Cancellation of bond
No surety on a discount card company bond shall cancel such bond without giving written
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notice thereof to the Secretary of State and discount card company.
Resident agent
The resident agent is a person who is a resident of Kansas authorized to accept service of
o
process (lawsuits) on behalf of the applicant. This does not necessarily mean that the agent
himself/herself is being sued, but that he/she has the authority and responsibility to accept
service of process on behalf of the applicant.
Registered office
The registered office is the address where the resident agent is located, which must be a
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numbered street address. A P.O. box is unacceptable.
Mailing address
The mailing address is where you would like to receive official mail from the Secretary of
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State’s office.
Signature
The health care card supplier requires the signature of any individual authorized by the card
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supplier.
Inst.
Please proceed to form.
K.S.A. 50-1,101
Rev. 2/2/16 tc
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