Fill and Sign the 2020 Form W 3 Transmittal of Wage and Tax Statements

VIRGINIA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES OFFICE OF CHARITABLE AND REGULATORY PROGRAMS PO Box 526 • Richmond, VA 23218-0526 (804) 371-0511 • Fax: (804) 225-2666 • www.vdacs.virginia.gov OCRP-71 Revised 06/13 REMITTANCE FORM CREDIT SERVICES BUSINESS ANNUAL REGISTRATION FEE: $100 (Name of Company) Registration fee Accounting Code: 973-09060 (Address) Check Amount Check Number Federal Employer Identification Number: 1) Have you enclosed all necessary items in your registration packet? 2) Have you completely answered each question and provided the proper exhibit? 3) Have you signed and had your registration notarized (Question 7 and end of form)? NOTICE Please make checks payable to: TREASURER OF VIRGINIA Please attach completed remittance form to the front of the registration application with a check and mail to: VDACS PO Box 526 Richmond, VA 23218-0526 The code of Virginia authorizes state agencies to assess interest, administrative charges and penalty fees for returned checks and past due accounts in accordance with the guidelines promulgated by the department of accounts. OCRP 71 1 VIRGINIA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES OFFICE OF CHARITABLE AND REGULATORY PROGRAMS PO Box 526 • Richmond, VA 23218-0526 (804) 371-0511 • Fax: (804) 225-2666 • www.vdacs.virginia.gov OCRP-71 Revised 06/13 APPLICATION FOR REGISTRATION CREDIT SERVICES BUSINESS 1. Name of business: Trading as: Business address(es): City: State: Zip: Telephone Type of business: Corporation Partnership Sole Proprietorship If corporation, state of incorporation: 2. Name of registered agent: Address: City: State: Zip: 3. List the name and address of any person who directly or indirectly owns or controls a ten percent or greater interest in the credit services business (Attach additional sheets if needed): 4. List the standard fees charged by your company with a brief explanation of the services performed for each fee. OCRP 71 2 APPLICATION FOR REGISTRATION CREDIT SERVICES BUSINESS 5. Revised 06/13 Provide the name and address of the surety company that issued a bond or the name and address of the bank that issued a letter of credit pursuant to § 59.1-335.4. Bond number or letter of credit number: Amount of bond or letter of credit: 6. Have you attached the bond or letter of credit? Yes No If no, please explain why. 7. Has there been any litigation or unresolved complaint filed against you within the preceding five years with a governmental authority of the Commonwealth, or the governmental authority of any other state or the United States relating to the operation of your credit services business? Yes No If yes, attach a complete description and explanation of the litigation or unresolved complaint, including a statement indicating in what jurisdiction the action or complaint is pending. If no, you must attest to the following: I certify that there has been no litigation nor any unresolved complaints within the preceding five years with a governmental authority of the Commonwealth, any other state or the United States relating to the operation of the credit services business. Date Signature This day, personally before me, Known to me to be such person and he/she signed and swore to the truth of the foregoing registration statement. Date Notary Public My commission expires: OCRP 71 3 APPLICATION FOR REGISTRATION CREDIT SERVICES BUSINESS Revised 06/13 8. Attach a copy of the information statement that you are required by §59.1-335.6, Code of Virginia, to provide to any consumer prior to entering into a contract for your services. 9. Attach a copy of all contracts which the credit services business intends to execute with its consumers. 10. Attach your check, payable to the "Treasurer of Virginia" in the amount of $100. Follow the instructions for mailing at the bottom of the remittance form. I certify that all the information contained in this registration statement is true and correct. Date Signature Print Name Title This day, personally before me, Known to me to be such person and he/she signed and swore to the truth of the foregoing registration statement. Date Notary Public My commission expires: Note: an authorized officer or agent must sign this registration form. Registration forms that are not completely filled out, signed and notarized will not be effective and the credit service business will be considered unregistered. OCRP 71 4