Section 177.ILLUSTRATION A – Credit Services Organization Registration Statement

STATE OF ILLINOIS

CREDIT SERVICES ORGANIZATION

REGISTRATION STATEMENT

($100 Filing Fee)

This registration statement, along with a $100 filing fee and a $100,000 surety bond are to be filed with the Secretary of State, Index Department, 111 East Monroe Street, Springfield, IL 62756.

When a change in the information contained in this statement occurs the credit services organization is required to file an amended statement within 90 days.  There is no fee for filing amended statements.

A credit services organization is required to continuously maintain a $100,000 surety bond if that credit services organization charges or receives any money or other valuable consideration prior to full and complete performance of the services the credit services organization has agreed to perform.  A bond shall also be maintained for a period of 2 years after the date that the organization ceases operations.

A file-stamped copy of this statement will be returned to the credit services organization who must maintain the copy in their files and allow a buyer to inspect the registration statement.

1.         Name and address of the credit services organization.

2.         Name and address of the registered agent or individual authorized to accept service of process on behalf of the credit services organization.

3.         Name and address of any and all persons who directly or indirectly own or control 10 percent or more of the outstanding shares of stock in the credit services organization. (If additional space is needed, attach a listing)

4.         If any, the bond number, name and location of the surety company issuing a $100,000 surety bond as required by the Credit Services Organizations Act.

5.         (A)      Has there been any litigation or unresolved complaint filed with a governmental authority of this State, any other state or the United States relating to the operation of this Credit Services Organization?               No        Yes

If answer is yes, you must attach a full and complete disclosure.

(B)      If there has been no litigation or unresolved complaint filed, the following statement must be completed and notarized.

do hereby affirm that there has been no litigation or unresolved complaint filed with a governmental authority of this State, any other State or the United States relating to the operation of this credit services organization.

6.         I do hereby affirm that the foregoing statements and any attachments are true and correct.