Free INDIANA MONEY TRANSMITTER LICENSE APPLICATION FORM - Indiana

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State of Indiana DEPARTMENT OF FINANCIAL INSTITUTIONS 402 West Washington Street, Rm W066 Indianapolis, Indiana 46204
State Form 48009(R/7-01)
DATE RECEIVED LICENSE #. DFI Use Only ________________ DFI ID #_____________

MONEY TRANSMITTER LICENSE APPLICATION
TO BE COMPLETED BY ALL APPLICANTS
Name of Applicant

Address ( Number and Street) Fax Number

City, State, Zip Code

Telephone Number

HOME OFFICE NAME AND ADDRESS: Home Office Name Address ( Number and Street) City, State, Zip Code Telephone Number Fax Number

Address of Where License is to be Sent

Contact Person Telephone Number Fax Number

City, State, Zip Code

OTHER BUSINESS LOCATIONS AND PROPOSED AUTHORIZED DELEGATES Number of other business locations in Indiana_________. Number of proposed delegates in Indiana ________. Attach a list of the locations where applicant and agents propose to conduct activities in Indiana. Attach a sample authorized delegate contract. ASSUMED NAME

If applicant operates under an assumed name, a certificate from the appropriate official showing compliance with the provisions of the laws of the State of Indiana pertaining to conducting business under an assumed name is to be included with the application.
INDIVIDUALS (To be completed by those operating as Individuals)
Name

Address ( Number and Street) Telephone Number

City, State, Zip Code

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PARTNERSHIPS ( To be completed by those operating as Partnerships)
NAME AND RESIDENCE ADDRESS OF EACH PARTNER: Name Address (Number and Street) City, State, Zip Code Name Address (Number and Street) City, State, Zip Code

Telephone Number

Telephone Number ATTACH AN ADDITIONAL SHEET IF NECESSARY

CORPORATIONS (To be completed by those operating as Corporations)
Name City, State, Zip Code Corporation Organized Under the Laws of What State? LIST OFFICERS AND DIRECTORS WITH TITLE AND RESIDENCE ADDRESS: Name Address (Number and Street) City, State, Zip Code Name Address (Number and Street) City, State, Zip Code Name Address (Number and Street) City, State, Zip Code Telephone Number ATTACH AN ADDITIONAL SHEET IF NECESSARY Telephone Number Telephone Number Telephone Number Date of Incorporation

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REFERENCES
Give three (3) names and addresses of references as to your "financial responsibility, character, and fitness." One shall be a representative of a financial institution. Reference letters on business stationery should be submitted with your license application.

Individual's Name Address (Street, City, State, Zip Code) Individual's Name Address (Street, City, State, Zip Code) Individual's Name Address (Street, City, State, Zip Code)

Title Telephone Number Title Telephone Number Title Telephone Number

THE FOLLOWING INFORMATION MUST BE ATTACHED TO ALL APPLICATIONS 1. History of material litigation and criminal convictions for the five (5) years before the date of application for each individual, partner, officer, or director. 2. Description of: activities conducted by applicant; business plan; history of operations; and business activities in which the applicant seeks to be engaged in Indiana.

3. A sample form of payment instrument, if applicable. 4. Name and addresses of clearing banks. 5. List of other states where you are operating as a money transmitter, giving State Agency, date licensed, contact person, and telephone number. 6. Documents revealing a net worth of the lessor of one hundred thousand dollars ($100,000); a) plus a net worth of fifty thousand dollars ($50,000) for each location and for each authorized delegate in Indiana; or b) a net worth of five hundred thousand dollars ($500,000).

7. A security device as provided for in Section 27 of the Act or a deposit as provided for in Section 29 of the Act.
8. POLICY OF INSURANCE AGAINST LOSS BY A CRIMINAL OR DISHONEST ACT: When a license is granted, each

licensee shall maintain a policy of insurance which insures the applicant against loss by a criminal act or act of dishonesty issued by an insurer authorized to do business in Indiana. The principal sum of the policy shall be equivalent to one-half (½) of the required security device required under section 27 or the deposit required under section.
9. THE APPLICABLE INFORMATION FROM THE CHECK LIST ON PAGE 5.

Sign Acknowledgment on Page 4.

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ACKNOWLEDGMENT

The applicant executed this application on and acknowledges that all statements made herein and supporting schedules, to the best of my/our knowledge and belief, are true and is a true and complete statement in accordance with the law. IF A CORPORATION, PRESIDENT AND ONE OFFICER MUST SIGN; IF A PARTNERSHIP, ALL PARTNERS MUST SIGN; IF SOLE PROPRIETORSHIP, OWNER MUST SIGN.
By: Printed Signed Name: By: Printed Signed Name: By: Printed Signed Name: By: Printed Signed Name: Title Title Title Title

ATTACH AN ADDITIONAL SHEET IF NECESSARY.

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CHECK LIST FOR MONEY TRANSMITTER LICENSE

CORPORATIONS ­ SECTION 25 OF THE MONEY TRANSMITTER ACT (IC 28-8-4-25)
The applicant must provide the following items and information relating to the applicant=s corporate structure: State of incorporation Date of incorporation Certificate of good standing from state of incorporation Description of corporate structure: Identity of the parent of the applicant Identity of each subsidiary of applicant Stock exchanges where applicant, parent, and subsidiaries are publicly traded. For each executive office, key shareholder, and person in charge of licensed activities: Name Business Address Residence address Employment history for the 5 years preceding the date of application. For each executive office, key shareholder, and director: History of material litigation for 5 years preceding date of application History of criminal convictions for 5 years preceding date of application. Copies of audited financial statements for the current year and the preceding 2 years, including: Balance sheet Statement of income or loss Statement of changes in shareholder equity Statement of changes in financial position Management letter. Or, if applicant is a wholly owned subsidiary of: a corporation publicly traded in the United States; financial statements for the current year or the parent corporation=s Form 10K reports filed with the United States Securities and Exchange Commission for the preceding 3 years may be submitted with the applicant=s unaudited financial statements; or a corporation publicly traded outside the United States; similar documentation filed with the parent corporation=s non-United States regulator may be submitted with applicant=s unaudited financial statements. Copies of filings, if any, made with the United States Securities and Exchange Commission, or with a similar regulator outside the United States, not more than one year before the date of filing of the application.

NON-CORPORATIONS ­ SECTION 26 OF THE MONEY TRANSMITTER ACT (IC 28-8-4-26)
The applicant must provide the following for each principal and each person who will be in charge of the applicant=s licensed activities. Name Business Address Residence Address Personal financial statement for the 5 years preceding the date of the application Employment history for the 5 years preceding the date of the application. Evidence that the applicant is registered or qualified to do business in Indiana. Date registered or qualified to do business in Indiana. For each individual having an ownership interest in the applicant and each individual who exercises supervisory responsibility with respect to the applicant=s activities the: History of material litigation for 5 years preceding date of application History of criminal convictions for 5 years preceding date of application. Copies of the applicant=s audited financial statements for the current year and, if applicable, for the preceding 2 years, including: Balance sheet Statement of income or loss Statement of changes in financial position Management letter. ALL APPLICANTS: Three reference letters, one must be a Financial Institution. Indiana Business Plan. List other State that Applicant has a License for Money Transmission. List addresses of branch locations.

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STATE OF INDIANA

DEPARTMENT OF FINANCIAL INSTITUTIONS

402 West Washington Street, Room W066 Indianapolis, Indiana 46204-2759 Telephone: (317) 232-3955 Fax: (317) 232-7655
TO APPLICANTS FOR A MONEY TRANSMITTER LICENSE:

Enclosed is an application for a Money Transmitter License (IC 28-8-4). To be considered for a license, the applicant must complete the application and submit it to the Department of Financial Institutions. There is no initial license application fee at this time. A license renewal fee of $200.00, plus $5.00 per location or delegated agent, up to a total maximum fee of $1,000.00 is due by December 31 each year. The Department will investigate the financial condition and responsibility, business and financial experience, character, and general fitness of the applicant. An on-site investigation may be conducted, the cost of which shall be borne by the applicant. A copy of the Money Transmitter Act is attached for your reference in completing the application. STATE POLICE REPORT: A criminal record report from the State Police of the State of residence for each owner, partner, or officer must accompany the application. The report from the Indiana State Police may be secured by sending a money order (amount determined by State Police) to the ISP Central Records Division, IGCN 100 North Senate, Room 302, Indianapolis, IN 46204, 317-232-8262. Include your name, address, date of birth, and your finger prints and request a review of records for the Department of Financial Institutions for the issuance of a Money Transmitter license. SECURITY DEVICE: An application for a license must be accompanied by a security device as required by Section 27 of the act or a deposit as required by Section 29 of the act. FINANCIAL STATEMENT: A Financial Statement revealing a net worth of the lessor of $100,000.00 plus a net worth of $50,000 for each location and for each authorized delegate in Indiana; or a net worth of $500,000. An audited Financial Statement is to be

attached to the application including a balance sheet, a statement of income or loss, a statement of changes in shareholder's equity, management letter, and a statement of changes in financial position; or if the licensee is a wholly owned subsidiary, the consolidated audited annual financial statement of the parent corporation filed with the licensee's unaudited annual financial statement.

PERMISSIBLE INVESTMENTS: A licensee must at all times possess permissible investments with an aggregate market value, calculated in accordance with generally accepted accounting principles, of not less than the aggregate face amount of all outstanding payment instruments issued or sold by the licensee or an authorized delegate of the licensee in the United States. The Director may waive the permissible investments required if the dollar value of a licensee's outstanding payment instruments do not exceed the security device posted by the licensee under section 27 or the deposit made by the licensee under section 29 of the Act. When a license is granted, each licensee shall maintain a policy of insurance which insures the applicant against loss by a criminal act or act of dishonesty issued by an insurer authorized to do business in Indiana. The principal sum of the policy shall be equivalent to one-half ( ) of the required security device required under section 27 or the deposit required under section 29 of the Act. Upon granting the license, a duly authenticated and numbered license will be forwarded to the address designated in the application. The licensee should show the assigned license number in all correspondence or communications with the Department subsequent to licensing. Licenses under the Indiana Money Transmitter Act are issued on the basis of representations made in the application. Any substantial change in the information included in the application should be reported to the Department within ten days after such change. Changes in the name requires the submission of the license to the Department for reissue. Changes in ownership of the holder of the license terminates the license. If you desire further information concerning specific questions, please contact this office.

NON-DEPOSITORY DIVISION

28-8-4-38 Renewal of licenses
Sec. 38. (a) A licensee may renew a license by complying with the following: (1) Filing with the director the annual report in the form that is prescribed by the director and sent by the director to each licensee not less than three (3) months immediately preceding the date established by the director for license renewal. The report must: (A) include: (i) a copy of the licensee's most recent audited consolidated annual financial statement, including a balance sheet, a statement of income or loss, a statement of changes in shareholder's equity, and a statement of changes in financial position; or (ii) if the licensee is a wholly owned subsidiary, the consolidated audited annual financial statement of the parent corporation filed with the licensee's unaudited annual financial statement; (B) the number of payment instruments sold by the licensee in Indiana, the dollar amount of those instruments, and the dollar amount of outstanding payment instruments sold by the licensee calculated from the most recent quarter for which data is available before the date of the filing of the renewal application, but in no event more than one hundred twenty (120) days before the renewal date; (C) material changes to the information submitted by the licensee on its original application that have not been reported previously to the director on any other report required to be filed under this chapter; (D) a list of the licensee's permissible investments; and (E) a list of the locations within Indiana at which business regulated by the chapter will be conducted by either the licensee or its authorized delegate. (2) Paying the annual renewal fee described under section 37 of this chapter. (b) A licensee that: (1) does not file a renewal report or pay the renewal fee by the renewal filing deadline set by the director; and (2) had not been granted an extension of time to do so by the director; shall be notified by the director, in writing, that a hearing will be scheduled at which the licensee will be required to show cause why its license should not be suspended pending compliance with these requirements. If after the hearing the license is not suspended, the director may require a daily late fee beginning with the date the renewal report or annual renewal fee is required by this chapter in an amount fixed by the department under IC 28-11-3-5. As added by P.L.421993, SEC.85.