Consumer Credit Notification Form - Utah Department Of Financial Institutions
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1
2STATE OF UTAH
CONSUMER CREDIT
Department of Financial Institutions
NOTIFICATION FORM
324 South State Street, Suite 201, SLC, UT 84111
Mailing Address: P.O. Box 146800, Salt Lake City, UT 84114-6800
(Title 70C, Utah Code)
Fax: (801) 538-8894
Tel: (801) 538-8830
Utah Business Name and Mailing Address
Do Not Write In This Space
1)
IF YOU LEND TO CONSUMERS (primarily for personal, family or household purposes), SELL OR PROVIDE GOODS OR SERVICES
ON A CREDIT BASIS TO UTAH CONSUMERS, MAKE CONSUMER LEASES OR TAKE ASSIGNMENTS OF CONSUMER DEBT,
YOU ARE REQUIRED TO FILE NOTIFICATION AND PAY THE NOTIFICATION FEE OF $100 AT LEAST 30 DAYS BEFORE
COMMENCING BUSINESS. Thereafter, renewals will be due on or before each January 31st. When complete, return the form along
Department of Financial Institutions
with a check or money order made payable to the
at the mailing address shown above.
2) Name of lender, provider, seller, lessor, or assignee
3) Submit a current copy of the Certificate of Existence issued by the Utah Department of Commerce, Division of Corporations.
4) Address of principal office (may be outside Utah)
City
State
Zip
Telephone
5) Addresses of all offices or places of business in Utah, if any (attach a separate sheet if necessary)
6) Name / Address of contact person for complaint resolution
City
State
Zip
Telephone
7) Name / Address in Utah of registered agent upon whom service of process can be made
8) Email address of person responsible for filing notification
9) Please indicate which types of consumer credit you are engaged in, or plan to engage in this year (check all that apply):
____ Financing of consumer goods
____ Financing of consumer services
st
____ Open end 1
mortgage loans
nd
____ 2
mortgage loans
____ Consumer leases
____ Unsecured consumer loans
____ Auto loans
____ Mobile home/RV loans
____ Premium financing
____ Consumer debt collection
____ Payday or deferred deposit loans
NMLS# ____________
(Additional registration required - dfi.utah.gov/money-services/deferred-deposit-lender)
____ Auto title loans
NMLS# ____________
(Additional registration required - dfi.utah.gov/money-services/title-lenders)
____ Other (please specify) _____________
I hereby certify that the information provided in this form is true and correct.
Print or type:
Name
Date
Signature
Title
10/15
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