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COLORADO UNIFORM CONSUMER CREDIT CODE

2017

RENT-TO-OWN INITIAL NOTIFICATION FORM

WEBSITE: WWW.COAG.GOV/UCCC EMAIL: UCCC@COAG.GOV

TELEPHONE: (720) 508-6012

YOU MUST COMPLETE ALL SECTIONS AND FORMS. IF A SECTION DOES NOT APPLY, PLEASE WRITE N/A.

ENCLOSE CHECK PAYMENT WITH SUBMISSION.

RETURN TO:

COLORADO DEPARTMENT OF LAW

UNIFORM CONSUMER CREDIT CODE

RALPH L. CARR COLORADO JUDICIAL CENTER

1300 BROADWAY, 6TH FLOOR

DENVER, CO 80203

MAKE CHECKS PAYABLE TO:

COLORADO UNIFORM CONSUMER CREDIT CODE

OR COLORADO UCCC

COMPLETE THE FOLLOWING:

1. LEGAL NAME:

2. ALL TRADE NAMES IN WHICH BUSINESS IS TRANSACTED:

3. PHYSICAL ADDRESS OF INDIVIDUAL OFFICE/STORE:

4. DATE IN WHICH RENTAL PURCHASE AGREEMENTS COMMENCED AT ABOVE INDIVIDUAL OFFICE/STORE:

5. PHYSICAL ADDRESS OF PRINCIPAL OFFICE (MABE BE OUTSIDE OF COLORADO):

6. ARE RENTAL PURCHASE AGREEMENTS MADE IN A PLACE OTHER THAN AT AN OFFICE/STORE IN COLORADO?

(CIRCLE ONE) YES

OR NO IF YES, HOW? ___ MAIL ___ INTERNET ___ OTHER ___________________________

7. NAME & ADDRESS OF COLORADO REGISTERED AGENT UPON WHOM SERVICE OF PROCESS MAY BE MADE:

FEE SCHEDULE

INITIAL NOTIFICATION FEE FOR THIS PHYSICAL LOCATION

$50.00

THE UNDERSIGNED HEREBY FILES NOTIFICATION OF INTENT TO ENGAGE IN MAKING RENTAL PURCHASE AGREEMENTS

WITHIN THE STATE OF COLORADO.

I HEREBY VERIFY THAT THE INFORMATION STATED ABOVE AND THE AMOUNT PAID ARE TRUE AND CORRECT.

X_____________________________________________________

___________________

SIGNATURE OF OWNER/OFFICER/PARTNER

DATE

_____________________________________________________

___________________

PRINTED NAME OF OWNER/OFFICER/PARTNER

TELEPHONE NUMBER

EMAIL ADDRESS

MANDATORY INFORMATION FOR SOLE PROPRIETORS (NOT OPEN TO PUBLIC INSPECTION). THIS INFORMATION IS REQUIRED BY §§ 14-14-113 AND 24-31-107,

C.R.S. AND MAY BE USED TO REVOKE, SUSPEND, OR DENY LICENSES OR NOTIFICATIONS AS DETERMINED BY THE STATE CHILD SUPPORT ENFORCEMENT AGENCY

FOR NONCOMPLIANCE WITH SUPPORT ORDERS OR SUBPOENAS/WARRANTS RELATING TO PATERNITY AND CHILD SUPPORT.

ALSO INCLUDE A PHOTOCOPY OF YOUR DRIVER’S LICENSE, STATE IDENTIFICATION CARD, OR OTHER PHOTO IDENTIFICATION.

COMPLETE HOME ADDRESS: ___________________________________________________________________ ________ SSN: _______________________

2017 CONTACT INFORMATION LIST

Colorado Uniform Consumer Credit Code

Please provide the following information and return with your notification form.

Company Name: _____________________________________________________________________

Contact Person for Notification Questions and General Mailings:

Name: _____________________________________________________________________________

Title: ______________________________________________________________________________

Address: ___________________________________________________________________________

___________________________________________________________________________

Email Address: ____________________________ Phone Number: _________________________

Contact Person for Compliance Examinations: Same as Above:

___

Name: _____________________________________________________________________________

Title: ______________________________________________________________________________

Address: ___________________________________________________________________________

___________________________________________________________________________

Email Address: ____________________________ Phone Number: _________________________

Contact Person for Consumer Complaints: Same as Above:

___

Name: _____________________________________________________________________________

Title: ______________________________________________________________________________

Address: ___________________________________________________________________________

___________________________________________________________________________

Email Address: ____________________________ Phone Number: _________________________

2017 OWNERSHIP–COLLECTION ACTIVITY QUESTIONNAIRE

Colorado Uniform Consumer Credit Code

Please provide the following information and return with your notification form.

Company Name:

____________________________________________________________________________

Provide the names of the owners, stockholders of the corporation, or the members of the

limited liability company and the percentage of each owner’s, stockholder’s, or member’s

ownership interest. For corporations: If publicly traded, list all entities holding 10% or

more of the stock; If privately held, the number of shares must equal 100% of stock.

(Attach additional pages if necessary)

Name % of Stock or Member Ownership

___________________________________________________________________________________

Collection Activity

1. Provide the name and address of each collection agency, engaged by the notifier, to

collect defaulted Colorado consumer rent-to-own transactions.

(Attach additional pages if

necessary)

Name of Company Address

___________________________________________________________________________________

2. Provide the name and address of each debt buyer, to whom the notifier sold defaulted

Colorado consumer rent-to-own transactions.

(Attach additional pages if necessary)

Name of Company Address

___________________________________________________________________________________

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