BAD CHECK DIVERSION PROGRAM REGISTRATION APPLICATION

STATE OF MAINE
BUREAU OF CONSUMER CREDIT PROTECTION
35 STATE HOUSE STATION
AUGUSTA, MAINE 04333-0035
TEL: (207)624-8527
FAX: (207)582-7699
FOR OFFICE USE ONLY

DATE NOTIFICATION REC’D:  _____________________

AMOUNT FEE REC’D: ____________________________

CASH [    ]       CC [    ]       CHECK [    ]

CHECK NO:  ____________________________________

CASH NUMBER:_________________________________

In accordance with the provisions of 32 M.R.S.A., 
§11013-A(5), application is hereby made for a registration
to operate a Bad Check Diversion Program.

1.	FULL TRADE NAME OF PRIVATE ENTITY OPERATING DIVERSION PROGRAM (including d/b/a):  ___________________________________________________________________________________________
	___________________________________________________________________________________________

2.	ADDRESS:  	______________________________________________________________________________

_____________________________________________________  TELEPHONE: (     ) _____________________

3.	ADDRESS OF DISTRICT ATTORNEYS OFFICES SPONSORING PROGRAM:  ___________________________________________________________________________________________

____________________________________________________  TELEPHONE: (     )______________________

4.	LIST THE FOLLOWING INFORMATION REGARDING THE BUSINESS STRUCTURE OF THE PRIVATE ENTITY:

			      OFFICERS/MEMBERS			DATE & PLACE	RESIDENCE	           PERCENTAGE OF
				   (TITLE)		NAME		     OF BIRTH	 ADDRESS	      STOCK OR OWNERSHIP
(a) Officers or
	Members:  __________________________________________________________________________________
_____________________________________________________________________________________________

(b)	Federal I.D. Number:  _________________________________________________________________________

(c)	Date incorporated or organized___________________ under the laws of the State of ______________________.

d)	Include a certified copy of the charter and articles of incorporation or certificate of formation and membership/partnership agreement.

(e)	If a foreign corporation, foreign limited liability company or foreign limited partnership:

(1)  Provide proof of filing with the office of Maine Secretary of State as a foreign corporation, L.L.C. or L.P.

(2)  Name and Address of Designated Agent upon whom service of process may be made in this State:
___________________________________________________________________________________________

	(3)  Include a duly executed Power of Attorney using the form supplied with the application.

5.	Has any individual listed under #4 been convicted in any state or federal court of the crime of forgery, 	fraud, obtaining money under false pretense, embezzlement, extortion, larceny, burglary, breaking and 	entering, robbery, criminal conspiracy to defraud, or bribery?                  .  If answered “YES,” furnish 	details on separate sheet and attach to application.

6.	Has the applicant, its parent or any affiliate ever had a financial services license in any State suspended or revoked? ________.  If answered “YES,” state on a separate sheet the date of the suspension or revocation, the State in which it occurred, the reason for the action taken and the name and address of the regulatory agency involved.

7.	QUALITY CONTROL:  Please initial the following statements to signify agreement with each condition:

	My company will comply with the criminal laws of the State of Maine.  _______

	My company will comply with the terms of the administrative support services contract and directives of the District Attorney’s Office. _______

	My company will not exercise independent prosecutorial discretion.	_______

         My company will contact any issuer of an alleged worthless check for the purposes of participating in a pretrial
         diversion program for issuers of worthless checks only:

Only as a result of a determination by the District Attorney that probable cause of a worthless check violation under state criminal law exists, and that contact with the issuer of an alleged worthless check for purposes of participation in the program is appropriate.  _______

		Only if the issuer of an alleged worthless check has failed to pay the worthless check after 
		demand for payment is made for the check amount pursuant to state law.	_______

	       My company will include as part of an initial written communication with an issuer of an alleged worthless check a 		        clear and conspicuous statement that:
a) The issuer of an alleged worthless check may dispute the validity of any alleged worthless check violation 														______
(b) When the issuer of an alleged worthless check knows, or has reasonable cause to believe, that the alleged worthless check violation is the result of theft or forgery of the check, identity theft or other fraud that is not the result of the conduct of the issuer of an alleged worthless check, the issuer of the alleged worthless check may file a crime report with the appropriate law enforcement agency.  _______

(c) If the issuer of an alleged worthless check notifies the private entity or the District Attorney in writing, not later than 30 days after being contacted for the first time, that there is a dispute pursuant to this subsection, before further restitution efforts are pursued, the District Attorney or an employee of that District Attorney must make a determination that there is probable cause to believe that a crime has been committed.  _______

      My company will charge fees only in connection with services under the administrative support services contract that
      have been authorized by the contract with the District Attorney.				_______

8.	Prepare on a separate sheet and attach to the application a résumé of previous business experience of the applicant or person who will be actively in charge of the registered office, indicating previous experience or qualifications that bear on the issue of competency in operating a bad check diversion program.

9.	List all States in which the applicant operates bad check diversion programs: ____________________________________________________________________________________________

10.  	Describe the flow of consumer payments in the process utilized by the applicant company.  Are payments sent to the applicant or to the District Attorney’s Office?  Are escrow accounts used?  If so, identify the financial institution where the trust account for collection from Maine residents will be maintained, and the number assigned by the institution to the account.  

11.  	Include a statement describing the exact nature of the proposed operations.

12.  	Include with the application specimen Contract with the District Attorney’s Office; Listing Sheet (how accounts are sent to your company), Debtor’s Work Card (or records of contracts), Debtor’s Receipt (for any cash payments), and Remittance Sheet (how proceeds are remitted to the District Attorney’s Office).  If any of these functions are computerized, sample screen prints may be submitted.

13.  	For applicants seeking to maintain their books and records outside of the State of Maine, please include on a separate sheet a statement from an officer of the applicant indicating the applicant’s willingness to produce those books and records upon request, pursuant to the requirements of our agency’s Rule 300, §2(B).

14.  	Include the name, title, address, and telephone number of the person to contact for the scheduling of routine compliance examinations: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

15.  	Include the name, title, address, and telephone number of the person to contact if our office receives consumer complaints regarding the activities of your company: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

16.    Include a check, made payable to “Treasurer, State of Maine,” based upon the Fee Schedule found below:

Section 1(D) of Rule 300 establishes a staggered licensing system based upon the trade names of applicants.  Applicants with names beginning with letters A - M shall have their licenses expire July 31 of every even-numbered year.  Applicants with names beginning with letters N - Z shall have their licenses expire July 31st of every odd-numbered year.  The license fee is $600, unless there are fewer than twelve months to the next scheduled date of license renewal, in which case the license fee is $300.  To determine the fee that is applicable to your application, refer to the table below: 

Applicants with trade names beginning with letters A - M

	If there are more than 12 months from the date of application to
	July 31st of the forthcoming even year:  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  - $600

If there are fewer than 12 months from the date of application to
July 31st of the forthcoming even year:  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  - $300

Applicants with trade names beginning with N - Z

If there are more than 12 months from the date of application to
July 31st of the forthcoming odd year:  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  - $600

If there are fewer than 12 months from the date of the application to
July 31st of the forthcoming odd year:  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  - $300

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Notice regarding Public Information

This application is a public record for purposes of Maine’s Freedom of Access Law, 1 MRSA § 401, et seq.  Public records must be made available to any person upon request.  Information that you supply as part of this application (except your Social Security number, fingerprint cards, residential addresses of officers and applicants’ credit reports) is public information.  Other licensing records to which this information may later be transferred are also considered public records.  Where permitted by law, your company’s name, license number, mailing address and other information listed on this application may be posted on the State’s website.  

* * * * * * * * * *

Maine law [5 M.R.S.A. §130 (1991)] requires assessment of $20.00 for any check returned by your bank for insufficient funds.

* * * * * * * * * *

(If a Corporation, affix
corporate seal here)

By:____________________________________

Title: __________________________________

STATE OF ______________________________

County 
of:                                      , ss.								                                  , 200_____

	Personally appeared the above-named                                                  and made oath to the truth of the statements subscribed,

          Before me, 
 
										________________________________
          Notary Public/Justice of the Peace     

PLEASE MAIL YOUR APPLICATION ADDRESSED AS FOLLOWS:

REGULAR MAIL (US Postal Service):

STATE OF MAINE
BUREAU OF CONSUMER CREDIT PROTECTION
35 STATE HOUSE STATION
AUGUSTA, ME 04333-0035

EXPRESS/OVERNIGHT MAIL (Other than USPS):

BUREAU OF CONSUMER CREDIT PROTECTION
GARDINER ANNEX
76 NORTHERN AVENUE
GARDINER, ME 04345