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http://www.sos.louisiana.gov/Portals/0/I1CollectionAgencyRegistrationtoNewEntityFilings.pdf

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JAY DARDENNE SECRETARY OF STATE

STATE OF LOUISIANA SECRETARY OF STATE

Commercial (225) 925-4704 (225) 922-0435 Fax Administrative Services (225) 925-4704 (225) 925-4726 Fax Uniform Commercial Code (225) 922-1193 (225) 922-0452 Fax

TRANSMITTAL INFORMATION For All Business Filings Please indicate below the level of service requested, payment and contact information
Routine Expedite $30 Check or Money Order Enclosed Credit Card Number: Expiration Date:

24 hour processing

Business Name (List exactly as it appears in documents)

Name of person filing document (evidence of filing will be mailed to this person, at address below)

Address

City

State

Zip Code

Daytime phone number

Fax number

Email address

NOTE: Louisiana Law requires all Louisiana notaries to print or type their name and notary or bar roll number on the document.

Mailing Address: P. O. Box 94125, Baton Rouge, LA * 70804-9125 Office Location: 8585 Archives Ave., Baton Rouge, LA * 70809 Web Site Address: www.sos.louisiana.gov
SS984 Rev. 10/08

Jay Dardenne Secretary of State

COLLECTION AGENCY/DEBT COLLECTOR REGISTRATION FORM
(Pursuant to R.S. 9:3534.5 B) Enclose $25 filing fee Make remittance payable to Secretary of State Do Not Send Cash Return to: Commercial Division P. O. Box 94125 Baton Rouge, LA 70804-9125 Phone (225) 925-4704 Web Site: www.sos.louisiana.gov

The full legal name of the Collection Agency or Debt Collector is

Previous Name of Collection Agency or Debt Collector is

Jurisdiction of Organization if Collector is a company

Address where legal process may be served

Name of Employer if Collector is an individual

Signature of Authorized Representative

Date INSTRUCTIONS 1. File this form along with the $25 filing fee with the Secretary of State's office. 2. You will receive a copy marked "Received and Filed" by the Secretary of State.

SS I-1

12/08