State Form 49718/form Lb 4 - Application For Registration As A Principal Manager Or An Originator
Download a blank fillable State Form 49718/form Lb 4 - Application For Registration As A Principal Manager Or An Originator in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete State Form 49718/form Lb 4 - Application For Registration As A Principal Manager Or An Originator with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10APPLICATION FOR REGISTRATION AS A PRINCIPAL MANAGER OR AN ORIGINATOR
State Form 49718
(R5 / 6-08)
/ Form LB 4
Approved by State Board of Accounts, 2008
Explanation and Instructions
Before completing this Application for Registration as a Principal Manager or an Originator, you should read and be familiar with
the Indiana Loan Broker Act, codified in Indiana Code 23-2-5 and the rules relating to the Act which are contained in Indiana
Administrative Code 710 IAC 1-22. You may access the statutes and rules through the Division’s website:
This properly completed application must be accompanied by:
•
A $200 non-refundable application fee for registration as a principal manager or a $100 non-refundable application fee for
registration as an originator, plus $32.25 for an FBI background check payable to: “Indiana Secretary of State.”
•
Complete set of fingerprints on an FBI fingerprint card (FD258)
•
Certificate of completion of academic instruction course(s)
•
Evidence that applicant for registration as a principal manager has three years of experience, acceptable to the
Commissioner as a loan broker or in financial services (if applicable); and
•
Any additional documentation needed to answer questions.
•
DO NOT include the instructions (pages 1-4 of this form)
NOTE: The certificate of registration will not be issued until the required criminal background report(s) has been received and
reviewed by the Secretary of State, Securities Division.
A PERSON WHO KNOWINGLY FILES WITH THE COMMISSIONER ANY DOCUMENT OR STATEMENT THAT
CONTAINS A FALSE REPRESENTATION OF A MATERIAL FACT IS SUBJECT TO THE REGISTRATION BEING
DENIED, SUSPENDED, OR REVOKED; THE IMPOSITION OF A CIVIL PENALTY OF UP TO $10,000 PER
VIOLATION; AND CHARGED WITH A CLASS C FELONY WHICH IS PUNISHABLE BY A FINE UP TO $10,000
PER VIOLATION AND UP TO EIGHT (8) YEARS OF IMPRISONMENT.
If the space provided for any answer is inadequate, complete your answer on a separate sheet, specifying the question to which it
relates and attach this sheet to the application. For each additional sheet you provide, sign and list the
applicant’s
name.
Submit your properly completed application along with any supporting documentation to the following address:
Indiana Secretary of State
Securities Division
302 W. Washington St., Room E – 111
Indianapolis, Indiana 46204
A. GENERAL INSTRUCTIONS
1. TERMS USED – See the following Explanation of Terms section regarding italicized words/phrases used throughout the
State Form 49718/Form LB 4.
2. CHECK whether you are applying for registration as a principal manager or as an originator.
3. AMENDMENTS – The applicant must notify the Division as required by Indiana Code § 23-2-5-10(i) of a change in any
information contained in this form by submitting amendments using State Form 49718/Form LB 4 within two business
days of the change. Check the “Amend Existing Registration” box, enter the registration number, submit the name of the
applicant in Section 1(A), circle (or otherwise identify) and complete the information that is being amended, and complete
Section 9. If the amendment filing is to change the individual’s name, enter the previous name in Section 1(A) and the new
name in Section 1(H). Appropriate supporting documentation includes, but is not limited to, copies of marriage
certificates, divorce decrees, or other legal documents evidencing both the prior and new names.
4. SURRENDER / CANCEL – When an applicant decides to cease activity under the registration, use State Form
49718/Form LB 4 to notify the Secretary of State, Securities Division by checking the “Surrender/Cancel” box. Use this
notification for various reasons including voluntarily leaving the industry, surrender in lieu of revocation, gained
exemption status, etc. Complete Sections 1(A), 4, and 9 then send the original certificate of registration along with the
State Form 49718/Form LB 4 to the Secretary of State, Securities Division.
State Form 49718 (R5 / 6-08) / Form LB 4
Page 1 of 10
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Fpllc-1 - Application For Registration As A Foreign Professional Limited Liability Company, Form Sra - Addendum To Business Organization And Registration Forms
Business
Related Categories
Parent category: Legal