Illinois Administrative Code
Title 14 - COMMERCE
Part 485 - IMMIGRATION SERVICES
Exhibit A - Registration Statement

Universal Citation: 14 IL Admin Code ยง A

Current through Register Vol. 48, No. 12, March 22, 2024

STATE OF ILLINOIS

OFFICE OF THE ATTORNEY GENERAL

CONSUMER FRAUD BUREAU

100 WEST RANDOLPH STREET - FLOOR 12

CHICAGO, ILLINOIS 60601

REGISTRATION STATEMENT OF IMMIGRATION SERVICE PROVIDER

NOTE: The Registrant shall not, by completing this form, construe such action as an approval or sanction of the business practices of the Registrant by the State of Illinois or the Office of the Attorney General.

Today's Date:______________________

This registration statement, together with verification of malpractice insurance and/or a surety bond in the amount of $100,000, is to be filed with the Office of the Attorney General. When a change in the information contained in either of these statement occurs, the registered immigration service provider must file a statement of amendments within 90 days.

1. Name of immigration service provider:________________________________________________

__________________________________________________________

Address, City, Zip Code:_____________________________________

__________________________________________________________

Area Code and Telephone:___________________________________

2. Legal description of immigration service provider (i.e., corporation, partnership, assumed name, etc.):

__________________________________________________________

__________________________________________________________

3. Name, address and telephone number of individuals authorized to accept service of process on behalf of the immigration service provider.

__________________________________________________________

4. Name, address and telephone number of any and all persons who directly or indirectly own or control 10% or more of the immigration service provider's business. (If additional space is needed, attach listing.)

__________________________________________________________

__________________________________________________________

5. Malpractice Insurance and/or Surety Bond Information.

Please check one of the following, and complete relevant sections below: ____ I have Malpractice Insurance ___ I have a Surety Bond

A. MALPRACTICE INSURANCE INFORMATION
1. Name, address, telephone of Malpractice Insurance

Carrier:______________________________________________

______________________________________________________

______________________________________________________

2. Policy No.:________________________________________

3. Policy Amount:_____________________________________

4. Expiration Date:____________________________________

B. SURETY BOND INFORMATION
1. Name, address, telephone of Bonding Company:

__________________________________________________________

__________________________________________________________

__________________________________________________________

2. Bond No.:___________________________________________

3. Bond Amount:________________________________________

4. Expiration Date:_______________________________________

6. Has there, during the existence of the immigration service provider's business operation, ever been any litigation or complaint filed against it by a local or governmental authority of the State of Illinois, any other state, or the United States, relating to the business operations of the registering immigration service provider?

____yes ____no

7. If the answer to question 6 above is "no," complete and notarize the following statement:

I, _______, under oath, do hereby affirm there has been no litigation or complaint filed against ________(name of provider) by any local or governmental authority of the State of Illinois, any other state, or the United States.

________________________

Signature of Affirmant, Title or Official Capacity

Subscribed and affirmed to before me this ____ day of _______, ____.

________________

NOTARY PUBLIC

(Seal)

8. If the answer to question 6 above is "yes," answer the following:
i) Name and address of the plaintiff or complainant.

__________________________________________________________

__________________________________________________________

ii) Name and address of the court or governmental office where the lawsuit or complaint was filed.

__________________________________________________________

__________________________________________________________

iii) Filing number of the lawsuit or complaint brought against the immigration service provider.

__________________________________________________________

iv) Date when the lawsuit or complaint was filed

__________________________________________________________

v) A brief description of the nature of the lawsuit or complaint.

__________________________________________________________

__________________________________________________________

__________________________________________________________

(Attach additional pages if necessary.)

vi) What outcome (i.e., trial, settlement)?

__________________________________________________________

__________________________________________________________

9. If the answer to question 6 above is "yes," complete and notarize the following statement:

I, _______, under oath, do hereby affirm the foregoing statements and affirm any and all attachments are true and correct.

__________________________________________________________

Signature of Affirmant, Title or Official Capacity

Subscribed and affirmed to before me this ____ day of ________, _____.

________________

NOTARY PUBLIC

(Seal)

Disclaimer: These regulations may not be the most recent version. Illinois may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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