Registration Of Credit Services Organization Form
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10REGISTRATION OF
CREDIT SERVICES
Secretary of State
ORGANIZATION
State of Iowa
As required by Iowa Code section 538A.5 the following credit services organization files its registration with the
secretary of state. PLEASE READ INSTRUCTIONS ON BACK BEFORE COMPLETING.
1.
Name of organization: __________________________________________________________________
2.
Address of organization: ________________________________________________________________
Street Address
___________________________________________________________________________________
City
State
ZIP
2a.
Address in Iowa if different than #2: ________________________________________________________
Street Address
___________________________________________________________________________________
City
State
ZIP
3.
Name and address of any person(s) directly or indirectly controlling 10% or more of the organization:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
(Please attach additional pages if needed)
4.
One of the following must be attached (please indicate):
A full and complete disclosure of any litigation or unresolved complaint filed with a governmental
authority of this state relating to the operation of the credit services organization.
A notarized statement that there has been no litigation or unresolved complaint filed with a govern-
mental authority of this state relating to the operation of the credit services organization.
5.
Phone number of organization: ______________________________________________
6.
Attached is a copy of the disclosure statement required by Iowa Code section 538A.6(1).
I certify under penalty of perjury and pursuant to the laws of the State of Iowa that the preceding is true and correct.
Name _________________________________________________ Title _____________________________________
for (organization name) _____________________________________________________________________________
Signature __________________________________________________________ Date ________________________
635_0203
The information you provide will be open for public inspection under Iowa Code section 22.11.
rev 1/1
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