California Code of Regulations
Title 10 - Investment
Chapter 3 - Commissioner of Financial Protection and Innovation
Subchapter 13 - Deferred Deposit Transaction Law
Article 1 - Applications
Section 2020 - Application for Deferred Deposit Transaction Licenses

1. Name of applicant: ___________________________________________________________________

Fictitious Business Name: ______________________________________________________

2. Applicant is organized and will do business as (check as applicable):

[ ] an individual

[ ] a partnership

[ ] a corporation

[ ] a limited liability company

[ ] other (please specify)

______________________________________________________________________

3. Applicant's licensed place of business shall be (Financial Code Section 23020):

Provide the following additional information for any mobile unit location:

Proposed area in which the mobile unit will operate:__________

4. The following must be completed if the applicant is an:

Individual:

The FULL first, middle (if no middle name, so indicate) and last name of the individual.

___________________________

(Name)

Those applying for a license as an individual must complete the enclosed form entitled Statement of Citizenship, Alienage, and Immigration Status. (See Exhibit D.)

5. The following must be completed if the applicant is a:

The partnership applicant was organized on ____________________(Date) in the State of ____________________.

The FULL first, middle (if no middle name, so indicate) and last name, and complete business address MUST be given for each general partner. Indicate if a general partner is the managing general partner.

(Please see Item 6 for persons owning or controlling, directly or indirectly, 10% or more of the outstanding interests. (See Financial Code Section 23008.)

6. The following must be completed if the applicant is a:

Applicant was organized on ____________________(Date) in the State of ____________________.

Indicate if any of the following positions do not exist within the entity selected above. For those positions within the entity, the FULL first, middle (if no middle name, so indicate) and last name, MUST be given for each person(s) occupying the positions listed below: (Attach additional sheets, if necessary.)

President/Chief Executive Officer:

___________________________

(Name)

Executive Vice President/Vice President:

___________________________

(Name)

___________________________

(Name)

Secretary:

___________________________

(Name)

Treasurer/Chief Financial Officer:

___________________________

(Name)

Directors:

___________________________

(Name)

___________________________

(Name)

___________________________

(Name)

Manager(s)/Member(s) (i.e., a manager member of an association, or a manager appointed or elected by the members of a limited liability company):

___________________________

(Name)

___________________________

(Name)

___________________________

(Name)

Trustee(s):

___________________________

(Name)

___________________________

(Name)

___________________________

(Name)

Any other officer with direct responsibility for the conduct of applicant's deferred deposit activity within the state:

___________________________

(Name)

___________________________

(Name)

___________________________

(Name)

List any person, as defined in Financial Code Section 23001 (other than those persons listed above) that owns or controls, directly or indirectly, 10% or more of the applicant. (See Financial Code Section 23008):

___________________________

(Name)

___________________________

(Name)

___________________________

(Name)

The FULL first, middle (if no middle name, so indicate), last name, complete business address, telephone number, and e-mail address, if any, must be given for each of the person(s) who will be in charge of the place of business.

7. Has the applicant been subject to any administrative action in California or any other state? If so, please provide details and attach a copy of any action. If NONE, so state. (Attach additional sheets, if necessary.)

___________________________

___________________________

___________________________

___________________________

___________________________

8. Please provide the name, address, and telephone number of the bonding agent to whom the Department can direct questions regarding the surety bond required in Exhibit B below.

9. Please provide a short description of your business plan.

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

10. The following items MUST be provided as exhibits to the application:

EXHIBIT A. Please provide financial statements, including a balance sheet of the applicant as of a date not more than ninety days prior to the date this application is filed, that indicate a minimum net worth of $25,000. (Financial Code Section 23007; the balance sheet may be unaudited.)

EXHIBIT B. Please provide a copy of a surety bond, including any and all riders and endorsements, in the amount of $25,000. The bond has to be in effect prior to the issuance of a license. Instructions and surety bond form acceptable to the Department of Corporations are enclosed. (Financial Code Section 23013.)

EXHIBIT C. Please provide, for each person named in Items 4, 5, and 6 of this application, a Statement of Identity and Questionnaire, form enclosed (Financial Code Section 23008), along with fingerprint information pursuant to California Penal Code Section 11077.1 and the cost of fingerprint processing. (Financial Code Section 23006.)

EXHIBIT D. FOR INDIVIDUAL APPLICANTS ONLY. Please complete the enclosed form entitled "Statement of Citizenship, Alienage, and Immigration Status For Application of Department of Corporations License or Certificate." (Title 10 C.C.R. Section 250.61.)

EXHIBIT E. Please retain the enclosed form entitled "Licensee Authorization of Disclosure of Financial Records" and complete and return it to the Corporations Commissioner upon receipt of the license. A person named in Items 4, 5, or 6 of this application who is authorized to sign on behalf of the licensee must sign this form. (Financial Code Sections 23005(b), 23024.)

EXHIBIT F. If the applicant will be doing business under a fictitious business name, provide a copy of the Certificate of Filing and Proof of Publication, both of which bear the County Clerk's filing stamp. Refer to Section 17000 of the Business and Professions Code for the requirements of filing this statement. (Financial Code Section 23023.)

1. An ORIGINAL certificate of good standing or qualification duly executed not more than sixty (60) days before filing this application by the Secretary of State of California showing that the applicant is authorized to do business in this State. The certificate must also indicate the original date of incorporation. (Financial Code Sections 23005(b), 23015.)

2. A copy of the notice filed with the Department of Corporations that the initial issuance of shares of stock was entitled to an exemption pursuant to Section 25102 of the Corporations Code or was qualified for issuance in some other manner. (Financial Code Sections 23005(b), 23015.)

1. A certificate of good standing or qualification duly executed not more than sixty (60) days before filing this application by the Secretary of State of the foreign state, or other proper authority, showing that the applicant is authorized to transact business in that state. The certificate must also indicate the original date of incorporation.

2 A certificate of good standing or qualification duly executed not more than sixty (60) days before the filing of this application by the Secretary of State of California showing that the applicant is authorized to do business in California.

3. A Consent to Service of Process (form enclosed). Service made pursuant to the terms of the consent to service of process shall have the same force and validity as if served personally on the applicant.

4. Name and address of the principal agent in California.

EXHIBIT I. If the applicant is a Trust, Limited Partnership or Limited Liability Company (domestic business entity) submit an ORIGINAL certificate of good standing, qualification, or other document duly executed not more than sixty (60) days before filing this application by the Secretary of State of California showing that the applicant is authorized to do business in California. The certificate must also indicate the original date of incorporation. (Financial Code Sections 23005(b), 23015.)

1. A certificate of good standing or qualification duly executed not more than sixty (60) days before filing this application by the Secretary of State of the foreign state, or other proper authority, showing that the applicant is authorized to transact business in that state. The certificate must also indicate the original date of incorporation.

2. A certificate of good standing or qualification duly executed not more than sixty (60) days before the filing of this application by the Secretary of State of California showing that the applicant is authorized to do business in California.

3. A Consent to Service of Process (form enclosed). Service made pursuant to the terms of the consent to service of process shall have the same force and validity as if served personally on the applicant.

4. Name and address of the principal agent in California.

EXHIBIT K. DECLARATION REGARDING LAW AND RULES. Please complete and attach the enclosed declaration regarding the applicant's knowledge of the Deferred Deposit Transaction Law and Rules. Only one responsible officer or director is required to complete this form.

EXHIBIT L: DECLARATION PURSUANT TO FINANCIAL CODE SECTION 23037(i). Please complete and attach the enclosed declaration regarding offering, arranging, acting as an agent for, or assisting a deferred deposit originator in the making of a deferred deposit transaction. Only one responsible officer or director is required to complete this form.

EXECUTION SECTION

Please indicate the name, address, title, telephone number and e-mail address (if applicable) of the person who should be contacted for information regarding this application. The license will also be mailed to this person unless otherwise instructed.

In the event of the issuance of a license, applicant agrees to comply with the requirements of the California Deferred Deposit Transaction Law and rules adopted, and orders issued, by the Commissioner of Corporations, and further agrees that in the event of any change of its officers, directors, or any persons named in this application, that an amendment to the application reflecting such change shall within sixty (60) days from the date of the change, be filed with the Commissioner of Corporations setting forth the change, the effective date of the change, the names of the persons involved in the change, and a statement of the qualifications of each successor person. (Financial Code Sections 23008, 23010.)

WHEREFORE, applicant requests that a license be issued by the Commissioner of Corporations authorizing applicant to engage in business under the California Deferred Deposit Transaction Law within the State of California.

The applicant has duly caused this application to be signed on its behalf by the undersigned, thereunto duly authorized.

The undersigned, on behalf of the applicant, acknowledges that this application and all exhibits thereto which are not designated as confidential are subject to public inspection pursuant to Section 250.9.1, Chapter 3, Title 10, California Code of Regulations. A request for confidentiality of certain documents may be requested pursuant to Section 250.10. If a request for confidential treatment is granted (or denied), the person making such request will be notified in writing.

I declare under penalty of perjury under the laws of the State of California that I have read the foregoing application, including all exhibits attached thereto, or filed therewith, and know the contents thereof, and that the statements therein are true and correct.

STATE OF CALIFORNIA DEPARTMENT OF CORPORATIONS EXHIBIT B INSTRUCTIONS FOR FILING OF SURETY BOND

The attached form contains the approved format for the Surety Bond as required by Financial Code Section 23013. Every company is required to obtain and maintain a surety bond.

1. The signature of the attorney-in-fact for the surety company.

2. A notarial jurat for the attorney-in-fact.

3. A power of attorney from the surety company.

4. Legal name of the licensee. Business name(s), if applicable, may also be included.

5. The signature of the licensee.

6. The notarial jurat for the signature of the licensee.

BEFORE THE DEPARTMENT OF CORPORATIONS OF THE STATE OF CALIFORNIA EXHIBIT BSURETY BOND OF DEFERRED DEPOSIT TRANSACTION LAW LICENSEE FINANCIAL CODE SECTION 23013

Bond No. ____________________

KNOW ALL MEN BY THESE PRESENTS:

That we

, as Principal, whose address for service is

___________________________

,

(Street Address, City, State and Zip Code)

and _________________________, a corporation, created, organized and existing under and by virtue of the laws of the State of ____________________ and an admitted Surety insurer authorized to transact a general Surety business in the State of California, as Surety whose address for service is ______________________________(Street Address, City, State and Zip Code), are held and firmly bound unto the Commissioner of Corporations of the State of California, for the use thereof and for the use of any person or persons who may have a cause of action against the Principal under the provisions of the California Deferred Deposit Transaction Law and all laws amendatory thereof and supplementary thereto now and hereafter enacted, in the total aggregate penal sum of ____________________ Dollars ($__________) (see Financial Code Section 23013), lawful money of the United States of America, to be paid to the Commissioner of Corporations of the State of California, or to any person or persons, for the use and benefit aforesaid, for which payment well and truly to be made, we bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally firmly by these presents.

The condition of the above obligation is such that--

WHEREAS, the above-named Principal has made application to the Commissioner of Corporations of the State of California for a license to engage in business under and pursuant to the provisions of the California Deferred Deposit Transaction Law, and is required under the provisions of the California Deferred Deposit Transaction Law to furnish a bond in the sum above named, conditioned as herein set forth:

NOW, THEREFORE, the Principal, and any and all agents and employees representing the Principal, shall faithfully conform to and abide by the provisions of the California Deferred Deposit Transaction Law and all laws amendatory thereof and supplementary thereto now and hereafter enacted, and of all rules and regulations lawfully made by the Commissioner of Corporations of the State of California under the California Deferred Deposit Transaction Law and shall honestly and faithfully apply all funds received and shall faithfully and honestly perform all obligations and undertakings under the California Deferred Deposit Transaction Law, and shall pay to the Commissioner of Corporations of the State of California and to any person or persons, for the use and benefit aforesaid, any and all moneys which become due or owing the State or to any such person or persons from the Principal under and by virtue of the provisions of the California Deferred Deposit Transaction Law.

1. That any person who sustains an injury covered by this bond may, in addition to any other remedy that he or she may have, bring an action in his or her own name upon this bond for the recovery of any damages sustained by him or her.

2. That the total aggregate liability of the Surety or sureties herein shall be limited to the payment of ____________________ Dollars ($_______________) (insert amount of the bond).

3. This bond may be canceled by the Surety in accordance with the provisions of Sections 996.320 and 996.330 of the Code of Civil Procedure of the State of California.

4. That, in the event either the Principal and/or the Surety under this bond are served with notice of any action commenced against the Principal or the Surety under the bond, the Principal and Surety as each is served with notice of action shall respectively and, within 10 days, give written notice of the filing of such action to the Commissioner of Corporations of the State of California, at the Los Angeles office of the Department of Corporations.

5. That, in the event the Surety under this bond makes full or partial payment on this bond the Surety shall immediately give written notice of such full or partial payment to the Commissioner of Corporations of the State of California, at the Los Angeles office of the Department of Corporations.

6. That the effective date of this bond shall be _________________________.

______________________________

Signature of Principal

______________________________

Typed or Printed Name of Principal

______________________________

Executed at (City and State)

I certify (or declare) under penalty of perjury that I have executed the foregoing bond under an unrevoked power of Attorney.

Executed in _________________________(City and State) on ____________________(Date) under the laws of the State of California.

______________________________

Signature of Attorney-in-Fact for Surety

______________________________

Printed or typed name of Attorney-in-Fact for Surety

ALL OF THE ABOVE SIGNATURES MUST BE NOTARIZEDSTATE OF CALIFORNIA DEPARTMENT OF CORPORATIONS EXHIBIT C

_________________________

_________________________

File No., if any

_________________________

Licensee (Company Name)

(Insert Department of Corporations file number, if any, and the name of the licensee (company) to which this Statement of Identity and Questionnaire relates.)

This document (together with any fingerprint information, if applicable) shall be treated by the Department of Corporations as being received in confidence pursuant to paragraph (4) of subdivision (d) of Section 6254 of the Government Code.

STATEMENT OF IDENTITY AND QUESTIONNAIRE

Position to be filled in connection with the preparation of this questionnaire (e.g. Officer, Director, Manager, etc.)

NOTE: See Commissioner's Release 2-G (Revised), attached, regarding whether or not furnishing the social security number is mandatory or voluntary and for a description of the use made of that information.

1. Residence addresses for the last 10 years:

NOTE: Attach separate schedule if space is not adequate

2. Employment for the last 10 years:

NOTE: Attach separate schedule if space is not adequate.

3. Have you ever been named in any order, judgment or decree of any court or any governmental agency or administrator, temporarily or permanently restraining or enjoining you from engaging in or continuing any conduct, practice or employment?

[ ] Yes [ ] No

If the answer is "Yes" give details:

___________________________

___________________________

4. Have you ever been refused a license to engage in any business in this state or any other state, or has any such license ever been suspended or revoked?

[ ] Yes [ ] No

If the answer is "Yes" give details:

___________________________

___________________________

5. Have you ever been convicted of or pleaded nolo contendere to a misdemeanor or felony other than traffic violations?

NOTE: "Convicted" includes a verdict of guilty by judge or jury, a plea of guilty or of nolo contendere or a forfeiture of bail. All convictions must be disclosed even if the plea or verdict was thereafter set aside and the charges against you dismissed or expunged or if you have been pardoned. Convictions occurring while you were a minor must be disclosed unless the record of conviction has been sealed under Section 1203.45 of the California Penal Code or Section 781 of the California Welfare and Institution Code.

[ ] Yes [ ] No

If the answer is "Yes" give details:

___________________________

___________________________

6. Have you ever been a defendant in a civil court action other than divorce, condemnation or personal injury?

[ ] Yes [ ] No

If the answer is "Yes" please complete the following:

Date of suit ____________________ Location of court ____________________

Nature of suit _____________________________________________

7. Have you ever been a subject of a bankruptcy or a petition in bankruptcy?

[ ] Yes [ ] No

If the answer is "Yes" give date, title of case, location of bankruptcy filing:

___________________________

___________________________

___________________________

8. Have you ever been refused a bond, or have you ever had a bond revoked or canceled?

[ ] Yes [ ] No

If the answer is "Yes" give details:

___________________________

___________________________

9. Have you ever changed your name or ever been known by any name other than that herein listed?

(Including a woman's maiden name) [ ] Yes [ ] No

If so, explain. Change in name through marriage or court order should also be listed. EXACT DATE OF EACH NAME CHANGE MUST BE LISTED.

___________________________

___________________________

10. Have you ever done business under a fictitious firm name either as an individual or in the partnership or corporate form?

[ ] Yes [ ] No

If the answer is "Yes" set forth particulars:

___________________________

___________________________

NOTE: The following questions must be answered by all persons submitting this questionnaire in connection with an ESCROW AGENT'S LICENSE.

11. In what capacity will you be employed?_________________________ (E.g., Clerk, Escrow Officer, Manager, Officer, Director, etc.)

12. Do you expect to be a party to, or broker or salesman in connection with escrows conducted by the escrow company which is employing you?

[ ] Yes [ ] No

If the answer is "Yes" please explain:

___________________________

___________________________

___________________________

NOTE: Attach separate schedule if space is not adequate.

This statement will be considered confidential information and will be filed and maintained as part of the confidential records not subject to public inspection.

VERIFICATION

I, the undersigned, state that I am the person named in the foregoing Statement of Identity and Questionnaire; that I have read and signed said Statement of Identity and Questionnaire and know the contents thereof, including all exhibits attached thereto; and that the statements made therein, including any exhibits attached thereto; are true.

I certify/declare under penalty of perjury that the foregoing is true and correct.

Executed at ____________________ (City)

this __________ day of ____________________, 20_____.

______________________________

(Signature of Declarant)

State of ______________________________)

County of ______________________________)

Date_________________________, 20_____

at ______________________________

______________________________

(Signature of Affiant)

Subscribed and sworn to before me ______________________________, 20_____

______________________________

Notary Public in and for said County and State

NOTE: This verification may be made either before a Notary Public or as a declaration under penalty of perjury. This form MUST be executed before a notary public if it is executed OUTSIDE the State of California.

STATE OF CALIFORNIA DEPARTMENT OF CORPORATIONS EXHIBIT E

LICENSEE AUTHORIZATION FOR DISCLOSURE OF FINANCIAL RECORDS

Pursuant to Financial Code Section 23024 and Government Code Section 7473, any financial institution, wherever situated, possessing financial records of

___________________________

(Name of Company as appears on Application)Licensed under the

CALIFORNIA DEFERRED DEPOSIT TRANSACTION LAW

is hereby authorized to disclose to the California Department of Corporations records of the above-named business licensed under the above-described Act, whether such records relate to accounts which have been closed, accounts which are currently maintained, or accounts which are hereafter established.

This authorization is effective as of the date of execution and shall remain effective until two (2) years after the expiration or revocation of the above-named business licensed under the above-described Act, including renewals of such license.

This authorization may not be revoked.

The terms used in this authorization shall have the definitions contained in the California Right to Financial Privacy Act (Government Code Section 7460 et seq.), and the California Deferred Deposit Transaction Law (Financial Code Section 23000 et seq.).

The above-named Licensee has duly caused this authorization to be signed on its behalf by the undersigned, thereunto duly authorized.

Executed on _______________ at_________________________(Provide date and city where executed)

______________________________

(Name of Licensee)

By _________________________

(Signature)

_________________________

(Title)

STATE OF CALIFORNIA DEPARTMENT OF CORPORATIONS

INSTRUCTIONS FOR LICENSEE AUTHORIZATION FOR DISCLOSURE OF FINANCIAL RECORDS FORM

On the reverse side is a Licensee Authorization for Disclosure of Financial Records form. The Commissioner of Corporations is authorized to require such authorization from licensees and other persons pursuant to the authority cited in Financial Code Section 23024.

The form must be properly executed and submitted prior to the issuance of a license, qualification, registration, or other authority, and as a condition therefor.

All information required on the form, except the signature of the person executing the form, is to be typewritten.

If additional authorization forms are needed, they may be obtained from any office of the Department of Corporations, or an accurate copy of the form may be used by applicant.

TO THE COMMISSIONER OF CORPORATIONS OF THE STATE OF CALIFORNIA

CONSENT TO SERVICE OF PROCESS EXHIBITS H AND J

KNOW ALL MEN BY THESE PRESENTS:

That the undersigned, ______________________________ (a corporation, partnership or limited liability company organized under the laws of the State of ______________________________),

hereby irrevocably appoints the Commissioner of Corporations of the State of California, or the Commissioner's successor in office, to be the undersigned's attorney to receive service of any lawful process in any noncriminal suit, action or proceeding against the undersigned, or the undersigned's successor, executor, or administrator which arises under the California Deferred Deposit Transaction Law or any rule or order thereunder after this consent has been filed, with the same force and validity as if served personally on the undersigned.

For the purpose of compliance with the California Deferred Deposit Transaction Law of the State of California, notice of the service and a copy of the process should be sent by registered or certified mail to the undersigned at the following address:

___________________________

(Name and Address)

___________________________

Dated: _________________________, _____.

[Insert name of corporation, partner-

ship, limited liability company or other

entity]

By ______________________________

Title ______________________________

OR

[Insert name of individual]

______________________________

ACKNOWLEDGMENT

State of California _________________________)

County of______________________________)

On _______________ before me, ______________________________(insert name and title of the officer) personally appeared ______________________________ who provided to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument are the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Signature______________________________ (Seal)

Any certificate of acknowledgement taken in another place shall be sufficient in the State of California if it is taken in accordance with the laws of the place where the acknowledgement is made.

STATE OF CALIFORNIA DEPARTMENT OF CORPORATIONS EXHIBIT KDECLARATION REGARDING LAW & RULES CALIFORNIA DEFERRED DEPOSIT TRANSACTION LICENSE

In the matter of the Application for a License under the California Deferred Deposit Transaction Law, I, the undersigned, authorized to act on behalf of the applicant, declare that the following statements are true and correct:

I (we) have obtained and read copies of the California Deferred Deposit Transaction Law (Division 10 of the California Financial Code) and the Rules (Chapter 3, Title 10, California Code of Regulations) and am familiar with their content; and,

I (we) agree to comply with all of the provisions of the California Deferred Deposit Transaction Law, including any rules or orders of the Commissioner of Corporations.

1. That the applicant will submit to periodic examinations by the Commissioner of Corporations as required by the California Deferred Deposit Transaction Law.

2. That the applicant will keep and maintain all records for two (2) years following the last entry on a deferred deposit transaction and will enable an examiner to review the record keeping and reconcile each consumer deferred deposit transaction with documentation maintained in the consumer's file records.

3. That the applicant understands the examination process involving the reconciliation of records will be facilitated if the applicant maintains, at a minimum, a ledger or listing of the following current and updated information for each deferred deposit transaction (as specified in Financial Code Section 23035): customer's name and address, account number, check number, amount provided, fee, amount of check, corresponding annual percentage rate (e.g. 14-day or 30-day), and the deferred due date.

4. That the applicant will maintain a file of all advertising for a period of ninety (90) days from the date of its use, which will be available to the Commissioner of Corporations upon request.

5. That the applicant will file with the Commissioner of Corporations an amendment to this application prior to any material change in the information contained in the application for licensure, including, without limitation, the plan of operation.

6. That the applicant will file with the Commissioner of Corporations any report required by the Commissioner.

7. That the applicant hereby attests that the applicant (including officers, directors and principals) has not engaged in conduct that would be cause for denial of a license. Only one declaration required for each applicant.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Executed on ____________________(date) at_________________________(place).

______________________________

(Signature)

______________________________

(Print name and title)

STATE OF CALIFORNIA DEPARTMENT OF CORPORATIONS EXHIBIT LDECLARATION PURSUANT TO FINANCIAL CODE SECTION 23037(i) OF THE CALIFORNIA DEFERRED DEPOSIT TRANSACTION LAW

1. The applicant will comply with all federal and state laws and regulations (including Division 10, commencing with Section 23000, of the Financial Code), if it offers, arranges, acts as an agent for, or assists a deferred deposit originator in the making of a deferred deposit transaction. (Financial Code Section 23037(i).)

2. The applicant will comply with all of the requirements of the exception specified in paragraphs (1) and (2) of subdivision (i) of Financial Code Section 23037, if it offers, arranges, acts as an agent for, or assists a state or federally chartered bank, thrift, savings association, or industrial loan company, in the making of a deferred deposit transaction. (Financial Code Section 23037(i)(1)(2).)

Will applicant engage in activities with a financial institution as described in number 2 above?

Yes [ ] No [ ]

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct to the best of my knowledge.

Executed on ____________________(Date) at _________________________(City and State).