Free - West Virginia

Secretary of State State Capitol Building 1900 Kanawha Blvd. East Charleston, WV 25305-0770

Filing Fee FEE: $50.00

Registration of Purchasers of Future Payments

Penney Barker, Manager Corporations Division Tel: (304) 558-8000 Fax: (304) 558-8381 www.wvsos.com

Hrs: 8:30 am - 5:00 pm

1.

The name and address of the Transferee:

2.

The name and address of the Transferee's agent for process, if any, is: The Transferee attests to: (Please check one of the following)

3.

There is no prior or pending litigation relating to the operations of the transferee. Organize as a West Virginia company

There are prior or pending litigations involving alleged violations of this article's provisions or consumer complaints filed with the Attorney General's Office of this state that allege violation of this article's provisions and attached is full disclosure of these alleged violations.

4.

By signing this registration the transferee also agrees to update statement within thirty days after a change of information occurs. Contact and Signature Information a. __________________________________________________ Contact Name b. __________________________________________________ Print or type name of signer Signature of Transferee: ___________________________________________
Business email address, if any:
Issued by the WV Secretary of State, State Capitol, Charleston, WV 25305 Revised 1/09

5.

________________________ Phone Number

c.
d.
FORM PFP

Date: _________________________

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