Fillable ARIZONA DEPARTMENT OF FINANCIAL INSTITUTIONS (Arizona)

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ARIZONA DEPARTMENT OF FINANCIAL INSTITUTIONS (Arizona)

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Country of origin: US
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ARIZONA DEPARTMENT OF FINANCIAL INSTITUTIONS
100 North 15th Avenue, Suite 261
Phoenix, AZ 85007
1 of 4
FE-LC-AP-DFI-Change_Application
Revised ϬϭͬϮϵͬϭϵ
Address Change
(check below)
Name Change
Duplicate License License Surrender
Primary Location
Corporation Location
Officer Change
Primary Email Address Change
Mailing Address Ownership Change
(Check the applicable box(es) for the change(s) being requested)
Telephone Number:
New Exact Name:
B. The above licensed location (2.A above) will be relocated to:
Address Line 2:
Legal Name:
Non-Mortgage Industry License Change Application (CHG)
Arizona Legal Name (as approved by the Arizona Corporation Commission or the Arizona Secretary of State):
1. Company Identifying Information:
A. Legal Name:
A. Licensed Location that is Changing its address:
State:
City:
License Type & Main License Number:
A. Name and/or DBA Name Change:
Address Line 1:
This application must be complete and legible
A license is not transferable or assignable and control of a licensee may not be acquired through a stock purchase or any other device
without the prior written consent of the Superintendent. List all individuals or entities owning 20% (15% for Money Transmitters) or more
voting shares only.
Branch Manager
Change
Responsible Individual Change
(Money Transmitter Only)
Active Manager
Change
Address Line 1:
Date Name Will Change:
Branch License Number (if applicable):
Zip Code:
A. Direct Ownership Change:
State:
Name:
Use a separate sheet if necessary
Name:
Encrypted Message Service Agreement Change
This New Location is ZONED as (check one)
Commercial Residential
City:
Name:
Doing Business As (DBA)/Trade Name: Optional. As approved by the Arizona Secretary of State:
3. Name and/or DBA Name Change:
Zip Code:
Fax Number:
Website:
2. Address Change:
Date Name Will Change:
Address Line 2:
New Exact DBA / Trade name (if applicable):
4. Ownership Change:
ARIZONA DEPARTMENT OF FINANCIAL INSTITUTIONS
100 North 15th Avenue, Suite 261
Phoenix, AZ 85007
2 of 4
FE-LC-AP-DFI-Change_Application
Revised ϬϭͬϮϵͬϭϵ
U.S. Citizen
A
T
A
T
Email Address:
Officer Title:
Add (A) or
Terminate (T)
(Check One)
Email Address:
Effective Date
of Change:
Effective Date
of Change:
Name:
Address of where records will be stored:
City:
State:
Zip:
Use a separate sheet if necessary
License Number Surrendering:
Address of License Surrendering:
City:
State:
Zip:
Name of contact:
Address of contact:
Effective Date of Change:
Name & Title:
Name & Title:
Effective Date of Change:
Use a separate sheet if necessary
License Number Surrendering:
Address of License Surrendering:
City:
State:
Zip:
6. Responsible Individual:
8. License Surrender:
A. License Surrender:
A. Responsible Individual:
This Responsible Individual Change form only pertains to Money Transmitters
7. Officer Changes:
A. Officer Changes:
Name:
Officer Title:
Add (A) or
Terminate
(T)
(Check One)
YES
NO
5. Active Manager:
B. Indirect Owners:
Title or Status
If a parent company is listed in section 5A, then list the direct owner of the parent company and designate name of the company.
% Ownership
Direct Owner Company Name
Phone # of Contact:
A. Active Manager:
Only pertains to Collection Agencies
Full Legal Name (Individuals: Last Name, First Name, Middle
Name)
Publicly Traded (symbol or n/a)
ARIZONA DEPARTMENT OF FINANCIAL INSTITUTIONS
100 North 15th Avenue, Suite 261
Phoenix, AZ 85007
3 of 4
FE-LC-AP-DFI-Change_Application
Revised ϬϭͬϮϵͬϭϵ
9. Duplicate License:
A. Duplicate License:
Print Title:
I hereby certify that to the best of my knowledge, this application contains no misrepresentation or omissions of material facts. An
Owner/Officer/Member/Authorized Person on file with our Department MUST sign this form.
11. Primary Email Change:
Provide the new primary email and its effective date. This email address is used to send your license electronically, renewal reminders
and any other important notifications that the department sends out relating to the license issued.
Primary Email Address:
Effective Date:
Signature:
Date:
Direct Telephone Number & Extension:
Address of Location:
City:
State:
Zip:
Branch License Number:
Fax Number:
Email Address:
License Number:
10. Branch Manager Change:
A. Branch Manager Change:
Print Name:
12. Authorized Individual:
Branch Manager Name:
Use a separate sheet if necessary
ARIZONA DEPARTMENT OF FINANCIAL INSTITUTIONS
100 North 15th Avenue, Suite 261
Phoenix, AZ 85007
4 of 4
FE-LC-AP-DFI-Change_Application
Revised ϬϭͬϮϵͬϭϵ
AzDFI Encrypted Message Service Instructions
Non-Mortgage Industry License Change Checklist
See Non-Mortgage License DFI-CHG-INSTRUCTIONS for specific fees
Authorized Individual shall be an Owner/Officer/Member/Authorized Person on file with AzDFI
Sign All Documents Where Applicable
Print or Type All Information on All Documents
Answer All Questions
on All Forms or Complete With “None” Or “NA”
Make Copies of the Completed Change Packet and any applicable documents for Your Records. For a
list of applicable documents see the DFI Change Instructions page at the link below:
See Non-Mortgage License DFI-CHG-INSTRUCTIONS
ENSURE THE LICENSE CHANGE APPLICATION HAS BEEN COMPLETED PRIOR TO
SUBMITTING TO THE DEPARTMENT. SUBMITTING A PARTIAL PACKAGE MAY
CAUSE A DELAY IN THE PROCESSING OF YOUR REQUEST.
Changes can not be made without all required items and applicable fees. Penalties may be
assessed for not complying. Enclose all applicable license change fee(s). Please review the DFI
Change Instructions for applicable fee(s).
ALL FEES MUST BE PAID FOR BY CHECK. CHECKS MUST BE SENT TO:
Arizona Dept. Financial Institutions
attn: Licensing Division
100 N. 15th Ave., Suite 261
Phoenix, AZ 85007
Background Check Instructions
Individual owners of 20% or more are required to complete a background check (15% or more for
Money Transmitters ONLY). All cost associated with a background check are paid for directly by the
applicant and must be completed prior to approval of any license type. Again, the applicant is
responsible for paying and obtaining the results. Once the background information is gathered, please
provide the results within your application submission. We kindly ask the background check is
completed prior to submission otherwise the application will be incomplete and will not be processed.
If you have any questions, please contact licensing at 602-771-2800, option 1.
Please select the “Instant Check” Option that reflects $24.95
Please click here
to start this process.
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ARIZONA DEPARTMENT OF FINANCIAL INSTITUTIONS (Arizona)

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Completed 20 July 2020

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