STATE OF WASHINGTON
DEPARTMENT OF FINANCIAL INSTITUTIONS
DIVISION OF CONSUMER SERVICES
P.O. Box 41200 Olympia, Washington 98504-1200
Telephone (360) 902-8703 TDD (360) 664-8126 FAX (360) 664-2258 http://www.dfi.wa.gov/cs
ESCROW AGENT AMENDMENT APPLICATION
Use this form if you are changing any of the following escrow agent company information:
Main office address
Branch office address
Main office name
Branch office name
Change of ownership or company personnel
Please see the following lists of instructions for each type of amendment.
ADDRESS CHANGE AMENDMENT
1) Complete Escrow Agent Application sections 1 & 2. If any information in sections 3,4, or 5 has changed you must
also complete those sections.
2) Submit all licenses showing the old address. Note: If this is for a main office address change, you must submit all
main office licenses as well as all branch office licenses.
3) Submit fee of $28.01 for each license that is being amended. (e.g.: Main office address change with DEO at main plus
1 branch and branch DEO = four licenses totaling $112.04). You may combine fees into a single check made
payable to “Washington State Treasurer.”
4) File address change documents with the Dept. of Licensing to update your Master Business License and with the
Secretary of State’s Division of Corporations for your Authority To Do Business. DFI will verify information
directly with these agencies.
5) Contact your insurance carrier to obtain an updated insurance certificate (E&O, Fidelity bond) and a Surety bond
rider (if you have a surety bond) showing the new address. Submit the original certificates as well as the surety bond
rider to DFI with this form.
NAME CHANGE AMENDMENT
1) Complete Escrow Agent Application sections 1 & 2. If any information in sections 3, 4, or 5 has changed you must
also complete those sections.
2) Submit all licenses showing the old name. Note: If this is for a main office name change, you must submit all
main office licenses as well as all branch office licenses.
3) Submit fee of $28.01 for each license that is being amended. (e.g.: Main office name change with DEO at main
plus 1 branch and branch DEO = four licenses totaling $112.04). You may combine fees into a single check made
payable to “Washington State Treasurer.”
4) File name change documents with the Dept. of Licensing to update your Master Business License and with the
Secretary of State’s Division of Corporations for your Authority To Do Business. DFI will verify information
directly with these agencies online. Note: You must check the availability of the desired new name with DFI as well
as the Secretary of State’s office. The Dept. of Licensing Master Business Licensing registers trade (dba) names as
well. Please don’t order signs, stationery, advertising, etc. until you have received confirmation from all agencies
that your chosen name is available.
5) Contact your insurance carrier to obtain an updated insurance certificate (E&O, Fidelity bond) and a Surety bond
rider (if you have a surety bond) showing the new name. Submit the original certificates (as well as the surety bond
rider) to DFI with this form.
CHANGE OF OWNERSHIP OR PERSONNEL
1) A 100% transfer of assets would require a new escrow agent application, and this form would not apply.
2) Complete Escrow Agent Application sections 1 & 2. If any information in sections 3, 4, or 5 has changed you must
also complete those sections.
3) Submit a before-and-after organizational chart which shows all owners, parents, subsidiaries, and affiliates as well as
percentages of ownership.
4) See section 5 of the Escrow Agent Application. Any incoming individuals that fall under those categories must
submit the Individual Background Form. If an individual currently associated with this escrow agent is changing
positions within the company, that individual must also complete the Individual Background Form.
5) Complete the Escrow Change of Control Form.
6) Submit fee of $30.00, made payable to “Washington State Treasurer.”
7) Do not use this form for changes in escrow officers – only company personnel that fall under section 5 of the Escrow
Agent Application. You must submit the Escrow Officer Application instead.
CHANGE OF DESIGNATED ESCROW OFFICER
Do not submit this form. For a change of Designated Escrow Officer you must submit the Escrow Officer Application. That
application contains instructions for submitting a change of DEO.
CHANGE OF BUSINESS STRUCTURE
A change of business structure (e.g.: corporation to LLC), change in state of incorporation, or change in federal tax
identification number would require a new escrow agent application, and this form would not apply.
Reference Telephone Numbers
Secretary of State, Corporations Division
Department of Licensing, Master Business Licensing
Office of the Insurance Commissioner
Office of the Attorney General
Escrow Association of Washington
(360) 753-7115
(360) 664-1400
(360) 753-7300
(360) 753-6200
(253) 864-3537
www.secstate.wa.gov/corps
www.dol.wa.gov/mls/buslic.htm
www.insurance.wa.gov
www.atg.wa.gov
www.e-a-w.org
DELIVERY – Keep copies of everything, and send original Company Form and all attachments to:
Via US Postal Service
Dept of Financial Institutions
Division of Consumer Services
PO Box 41200
Olympia WA 98504-1200
Via other couriers (eg: FedEx, UPS, etc)
Dept of Financial Institutions
Division of Consumer Services
150 Israel Rd SW
Tumwater WA 98501
STILL NEED HELP? Contact DFI’s Division of Consumer Services licensing staff by phone at 360-902-8703 or send your
questions via e-mail to DCS@dfi.wa.gov for additional assistance.
MAIN OFFICE
APPLICATION $386.55
ESCROW AGENT APPLICATION FORM
COMPANY
FORM
LICENSE
BRANCH OFFICE APPLICATION
$386.55
Date of Filing (MM/DD/YYYY):
Desired Effective Date (MM/DD/YYYY):
MAIN OFFICE AMENDMENT
BRANCH OFFICE AMENDMENT
DFI License Number (branch office and amendments only) 540-EAAMENDMENTS ONLY (check all that apply)
MAIN OFFICE ADDRESS CHANGE
MAIN OFFICE NAME CHANGE
OTHER
1ST
BRANCH OFFICE ADDRESS CHANGE
BRANCH OFFICE NAME CHANGE
BUSINESS STRUCTURE CHANGE
OWNERSHIP CHANGE
1.
EXACT NAME, PRINCIPAL BUSINESS ADDRESS, MAILING ADDRESS (IF DIFFERENT FROM BUSINESS ADDRESS), AND TELEPHONE
NUMBERS OF APPLICANT:
(A) Entity name
(sole proprietors provide last, first, and full middle name)
(B) IRS Employer Identification Number
(Social Security Number is allowed for sole proprietorship)
(C) (1) Trade name under which business primarily is or will be conducted, if different from Item 1A:
(2) List any other name(s) by which the applicant conducts or will conduct business and the jurisdiction(s) in which the name(s) are or will be used
(Use additional sheets as necessary).
Name
Jurisdiction
Name
Jurisdiction
Name
Jurisdiction
(D) For amendments only: If this filing makes a name change on behalf of the applicant, enter the new name and specify whether the name change is
of the
applicant name (1A) or
business trade name (1C):
(E) Main address: (Do not use a P.O. Box)
Number & Street
City
State / Province & Country
Zip+4 / Postal Code
State / Province & Country
Zip+4 / Postal Code
(F) Mailing address, if different from Main address:
PO Box or Number & Street
City
(G) Telephone Numbers and Website:
(
)
Business Phone
ext
(
)
Fax Line
-
____________
Website address
_______________
e-mail address (optional)
(H) Other than the office in 1E, does the applicant conduct business with consumers through branch locations?
YES
(Branch locations must be approved prior to conducting business. Use this form to submit a branch office application.)
NO
AUTHORIZATION FOR VERIFICATION – COMPANY
TO WHOM IT MAY CONCERN:
I, the undersigned official, of the company noted, hereby authorize and request you to provide the Department of Financial Institutions of the State of
Washington, any and all information and documentation that they request for the purpose of verifying information provided in conjunction with an application for
an escrow agent license, or for the purpose of conducting an investigation in accordance with chapter 18.44 Revised Code of Washington.
BY:
____________________________________
Signature of Authorized Official
__________________
Date
____________________________________
Printed Name of Authorized Official
__________________
Title
Applicant(company) full legal name:
2.
________________________________________
CONTACT INFORMATION FOR APPLICANT:
(A) Contact person for this application:
Name and Title
(
)
Business Phone
PO Box or Number & Street
ext
City
(
)
Fax Line
e-mail address
State / Province & Country
Zip+4 / Postal Code
(
)
Fax Line
e-mail address
(B) Contact person for future compliance issues (if different from above):
Name and Title
(
)
Business Phone
PO Box or Number & Street
ext
City
-
State / Province & Country
Zip+4 / Postal Code
(C) Physical address of location where the official books and records of the applicant will be kept. This is for the purpose of periodic review and
examination by the Department of Financial Institutions.
Records Custodian Name
(
)
Business Phone
Number & Street
ext
City
(
)
Fax Line
e-mail address
State / Province & Country
Zip+4 / Postal Code
State / Province & Country
Zip+4 / Postal Code
(D) Registered Agent:
Name
(
)
Phone
Number & Street
-
ext
City
Social Security Number
Date of Birth
DFI will send a specific Consent to Serve letter to the registered agent.
Note: If your office is outside the borders of Washington State, you must maintain a registered agent inside Washington.
If your office is within the borders of Washington State, the use of a registered agent is optional (your office staff may serve as registered agent). However, if
your company has used a registered agent when filing with other Washington state agencies, please provide this office with information about that registered
agent.
3.
STATE REFERENCE: Enter appropriate number in the box for each jurisdiction where the applicant is or has ever been licensed to engage in any escrow
or real estate related business.
Enter “1” if applicant is newly applying in that jurisdiction.
Enter “2” if applicant has a pending application in that jurisdiction.
Enter “3” if applicant is already licensed/registered in that jurisdiction.
Enter “4” if applicant is surrendering/canceling in that jurisdiction.
Enter “5” if applicant was formerly licensed/registered in that jurisdiction.
STATE
AL
FL
LA
NE
OK
VT
AK
GA
ME
NV
OR
VA
AZ
HI
MD
NH
PA
WA
AR
ID
MA
NJ
RI
WV
CA
IL
MI
NM
SC
WI
CO
IN
MN
NY
SD
WY
CT
IA
MS
NC
TN
DE
KS
MO
ND
TX
Guam
DC
KY
MT
OH
UT
Puerto
Rico
For each state marked, attach a STATE REFERENCE ADDENDUM which includes: name of licensee, type of license, license number, and the name, address,
phone, fax, and contact person of the regulatory entity issuing the license.
Applicant(company) full legal name:
4.
____________________________________
LEGAL STATUS OF APPLICANT:
Corporation
Proprietorship
Other (specify)
Partnership
Limited Liability Company
FEDERAL TAX IDENTIFICATION NUMBER:
WASHINGTON STATE UNIFIED BUSINESS ID NUMBER (UBI):
To obtain a UBI, you must contact the Washington State Department of Licensing, Business and Professions Division (360) 664-1400 to apply for (your) the
applicant’s Washington State Master Business License. A copy of this document is not required with your application. DFI will verify with the Department of
Licensing that (you) the applicant (have) has registered.
If the applicant is a corporation, partnership, or LLC you must contact the Washington Secretary of State, Division of Corporations, (360) 753-7115 to register
the applicant. A copy of this document is not required with this application. DFI will verify with the Secretary of State that the applicant has been registered.
DATE OF INCORPORATION:
STATE OF INCORPORATION:
APPLICANT’S FISCAL YEAR END (MM/DD):
If applicant is a publicly traded corporation, please insert stock symbol:
5.
INDIVIDUAL INFORMATION: The following individuals must attach and submit the INDIVIDUAL BACKGROUND FORM.
*Individuals holding these positions of control must also provide a personal credit report which includes a public records search and a pair of fingerprint
cards.
CORPORATION/LLC
PARTNERSHIP
SOLE PROPRIETORSHIP
Officer* (VP and above)
General Partners*
Owner*
Directors
Spouse of Owner
Principals* (10% or more ownership)
ESCROW AGENT SIGNATURE AND OATH OF APPLICANT
I hereby swear and affirm that the information contained herein and attachments hereto are true and correct to the best of my knowledge. Further, the
provisions of Revised Code of Washington 18.44 and Regulations promulgated by the Department of Financial Institutions in furtherance of such Code
provisions and contained in Washington Administrative Code have been reviewed by the principals and responsible parties of the applicant as listed herein, and
all employees of the applicant will be made aware of such laws and regulations and changes enacted hereafter. This application is submitted in furtherance of
the applicant’s desire to obtain from the Director of the Washington Department of Financial Institutions, a license to engage in the business of an escrow agent,
as defined in chapter 18.44 RCW. Any false statement or omission of material information in connection with this application shall be punished as provided by
law and may subject the applicant to denial of a license or the revocation of any license granted.
BY:
____________________________________
Signature of Authorized Official
__________________
Date
____________________________________
Printed Name of Authorized Official
__________________
Title
OWNERSHIP and
PERSONNEL
CHANGES
1.
CHANGE OF CONTROL
CHANGE OF OWNERSHIP
Applicant full legal name:
Date:
ESCROW CHANGE OF CONTROL APPLICATION
FORM
$30 fee, made payable to
“Washington State Treasurer”
Use this form to apply for changes of control and ownership. Changes of control include: change of ownership, or change of an executive officer, director,
manager, trustee, or other controlling person. If there is a change of ownership, you must provide a before-and-after organizational chart which shows all
parents, subsidiaries, affiliates, and percentages of ownership.
In the Type of Amendment (“Type of Amd.”) column, indicate “A” (addition), “D” (deletion), or “C” (change in information about the same person).
Note: A change of business structure (e.g.: corporation to LLC), change in state of incorporation, change in federal tax identification number, or a 100%
transfer of assets would require a new escrow agent application, and this form would not apply.
2.
List all changes below
FULL LEGAL NAME
(Individuals: Last Name, First Name, Middle Name)
Type
of
Amd.
Title or Status
% Ownership
Publicly Traded
S.S. No., IRS Tax
No. or Employer ID
REQUIRED ATTACHMENTS FOR A CHANGE OF CONTROL:
1. A before-and-after organizational chart showing all parents, subsidiaries, affiliates, and percentage of ownership.
2. Individual Background Forms and personal credit reports – The following incoming individuals must attach and submit the INDIVIDUAL
BACKGROUND FORM. *Individuals holding these positions of control must also provide a personal credit report (which includes a public
records search) and a pair of fingerprint cards. If an individual has provided fingerprint cards within the past 2 years for an escrow
application, there is no need to submit new fingerprint cards.
CORPORATION/LLC
PARTNERSHIP
SOLE PROPRIETORSHIP
Officer* (VP and above)
General Partners*
Owner*
Directors
Principals* (10% or more ownership)
3. Fee of $30, made payable to “Washington State Treasurer”.
Spouse of Owner
INDIVIDUAL
BACKGROUND
FORM
NEW APPLICATION
AMENDMENT
To amend, circle or identify
item(s) being amended.
WASHINGTON ESCROW BIOGRAPHICAL
STATEMENT AND CONSENT
Effective Date:
Date of Filing:
This form must be completed by each of the following individuals (check all boxes that apply)
Partnership
Corporations
Escrow Officer*
Sole Proprietorship
Officer* (VP and above)
General Partners*
Owner*
Directors
Spouse of Owner
Principal* (10% or more)
Percent owned:
1.
* Individuals holding these positions
of authority must also provide a
personal credit report (which includes
a public records search) and a pair of
fingerprint cards. If fingerprint cards
have been submitted within the past
two years, they don’t need to be
resubmitted.
Individual’s Identifying Information:
(A) Full last, first and middle names:
Last Name
First Name
(B) Social Security Number:
Middle Name
______________
(D) Date of Birth (MM/DD/YYYY)
(C) Gender
Suffix (if any)
Male
Female
(E) State/Province of Birth
(F) Country of Birth
_______
(G) List all name(s), other than your legal name, you have used or are using, or by which you are or were known since the age of 18. This field should
include for example nicknames, aliases, and names used before or after marriage. (Use additional sheets if necessary).
Name:
Name:
Name:
Name:
(H) For Amendments Only. If this filing reports that an individual’s name has changed, enter the new name and attach supporting legal documentation.
Last Name
First Name
Middle Name
(I) Employer Name (Escrow Agent):
DFI License Number (amendments only) 540-EA(J)
Suffix (if any)
Position:
Office of Employment: (Do not use a P.O. Box)
If this address is your private residence, check here
Number and Street
City
State/Country
Zip+4/Postal Code
State/Country
Zip+4/Postal Code
(K) Current Residence Address (if different from employment address):
PO Box or Number and Street
(L)
City
Telephone Numbers and email address:
(
)
-
ext
Business Phone
(
)
-
Cell Phone (optional)
(M) Drivers License Number:
(
)
-
Fax Line (optional)
______________
Email Address (Optional)
State issued:
(N) Are you a bona fide resident of the state of Washington?
YES
NO
(O) Do you agree to personally manage the office indicated in this application? (For DEO or Branch DEO only)
YES
NO
N/A
AUTHORIZATION FOR BACKGROUND INVESTIGATION – INDIVIDUAL
TO WHOM IT MAY CONCERN
I hereby authorize and request that all local, municipal, city, county, state and federal law enforcement authorities furnish such information as
they may have available concerning me, including information regarding criminal records, investigations, background, or similar information,
whether known to me or otherwise, to the Department of Financial Institutions of the State of Washington. My signature below authorizes the
Department of Financial Institutions of the State of Washington to obtain a personal credit report through an impartial credit reporting agency.
It is understood that the Department shall be under no obligation to disclose such information to me or any other person and may accept such
information under such conditions concerning confidentiality and disclosure as the person providing such information shall require.
BY:
____________________________________
Signature of Individual
__________________
Date
___________________________________
Printed name of Individual
__________________
Title
Individual full legal name:
___________________
Applicant (company) full legal name:
____________
2.
Residential History Starting with current address (item 1K), give all addresses for the past 10 years. (Attach additional sheets as necessary.):
From
Zip or Postal
To
Street Address
City
State or
Country
Province
Code
(MM/YYYY)
(MM/YYYY)
3.
Employment History: Provide complete employment history for the past 10 years. Account for all time including full & part-time employments, selfemployment, military service, and homemaking. Also include periods such as unemployed, full-time student, extended travel, etc. Indicate by “YES” or “NO”
whether this employment was financial service-related business. (Attach additional sheets as needed.)
From
Zip or Postal
To
Employer
City
State or
YES or NO?
Province
Code
(MM/YYYY)
(Company Name)
(MM/YYYY)
4.
Disclosures: If the answer to any of the following is “YES”, provide complete details of all events or proceedings in a DISCIPLINARY HISTORY
ADDENDUM.
DISCLOSURES
(1) With the exception of motor vehicle violations, have you ever been convicted of a crime, felony, or misdemeanor in this state, any other state,
the federal government, or any other jurisdiction within the past ten years? (NOTE: If you have been convicted of a crime, you will be subject to
an investigation, and you may be denied a license.)
(2) Is there a criminal complaint, accusation, or information presently pending against you, or are you under indictment in this state, any other
state, by the federal government, or by any other jurisdiction?
(3) Has any professional or occupation license or permit issued to you, or your right to engage in any business, ever been refused, suspended,
revoked, or denied in this state or any other jurisdiction?
(4) Have you ever had a civil order, verdict, or judgment entered against you in any court of competent jurisdiction in which the subject matter
involved any real estate or business related activity?
(5) Have you ever been discharged or requested to resign by any employer, or otherwise sever your business relationship with any person,
because of dishonest or unethical actions alleged to have been committed by you?
(6) Has a bonding company ever denied, paid out on, or revoked a bond for you?
YES
NO
