STATE OF MAINE
BUREAU OF CONSUMER CREDIT PROTECTION
35 STATE HOUSE STATION
AUGUSTA, ME  04333-0035
TELEPHONE:  (207) 624-8527    FAX: (207) 582-7699
MAINE CONSUMER CREDIT CODE

NEW FILER CALENDAR YEAR ____________

ANNUAL NOTIFICATION

FOR OFFICE USE ONLY

DATE NOTIFICATION REC’D: _______________

AMOUNT FEE REC’D: ______________________

CASH [     ]    CHECK [      ]   CREDIT CARD [      ]

CHECK NUMBER: __________________________

CHECKED BY: _____________________________

DATE ENTRY: _____________________________

In accordance with the provisions of the Maine Consumer Credit Code, this notification is hereby filed with the Superintendent of the Bureau of Consumer Credit Protection.

1.	BUSINESS NAME: __________________________________________________________

2.	ADDRESS:  ________________________________________________________________

3.	CITY/TOWN: ________________________  STATE: _____________ ZIP: ___________

4.	D/B/A:  __________________________________________  FEIN/SS#: ________________

5.	TELEPHONE: _____________________________ COUNTY:  ______________________

6.	NUMBER OF ADDITIONAL LOCATIONS THAT EXTEND CREDIT TO MAINE CONSUMERS: ________________________  ADDRESSES:  _______________________

___________________________________________________________________________
(Use separate sheet if necessary)

7.	A.  LOCATION OF RECORDS OF CREDIT TRANSACTIONS: ___________________
___________________________________________________________________________

	B.  CONTACT PERSON:  Include the name, title, address and telephone number of the person to contact for the scheduling of our compliance examination: __________________________

     ____________________________________________________________________________

8.	BUSINESS STRUCTURE:

[        ]   PROPRIETORSHIP    [        ]   PARTNERSHIP   [        ]   CORPORATION

A.  NAMES AND ADDRESSES OF PROPRIETOR, PARTNERS, OR CORPORATE OFFICERS, AS APPROPRIATE: ____________________________________________________________________
____________________________________________________________________________________
(Use separate sheet if necessary)

B.	TYPE AND DESCRIPTION OF BUSINESS 
1.	List type and description of business (Store, Hardware dealer, Rent- to-Own or Mobile Home Dealer, etc.):
______________________________________________________________________________

NOTE:  Please attach copies of contracts issued and signed by consumers.

9.  NAME AND ADDRESS OF PERSON TO WHOM WE MAY SEND LEGAL NOTICES:  _________________________________________________________________________________
________________________________________________________________________________________

10.  **FOR STATISTICAL PURPOSES ONLY **  IN ACCORDANCE WITH SECTION 6-104(1)(D) OF THE MAINE CONSUMER CREDIT CODE, THE OFFICE REQUIRES DISCLOSURE OF THE FOLLOWING INFORMATION, WHICH WILL BE DE-IDENTIFIED AND USED FOR STATISTICAL PURPOSES ONLY.  

NUMBER OF MAINE REPOSSESSIONS DURING the last calendar year – (Motor Vehicles, Boats, Snowmobiles, etc.):   ________________________________________

11.  LIST SALES FINANCE COMPANIES, BANKS OR OTHERS TO WHICH CONSUMER CREDIT TRANSACTIONS WERE ASSIGNED (e.g. GECAP, GMAC, FORD MOTOR CREDIT, ACME TRUST CO., SAVINGS BANK, FINANCE COMPANY) DURING THE PAST CALENDAR YEAR AND THE DOLLAR AMOUNTS ASSIGNED:

NAME					ADDRESS				       VOLUME
_______________________________________________________________   $____________
_______________________________________________________________   $____________
_______________________________________________________________   $____________

12.  ORIGINAL UNPAID BALANCES OF ALL CONSUMER CREDIT TRANSACTIONS ENTERED INTO IN MAINE DURING THE PAST CALENDAR YEAR. INCLUDE, UNDER #12(B), ALL AMOUNTS ASSIGNED TO FIRMS LISTED IN #11 ABOVE UNLESS THOSE FIRMS HAVE ALREADY PAID THE VOLUME FEE.  IF THEY PAID THE VOLUME FEE, LEAVE #12(B) BLANK.  (If uncertain, contact your assignee.)

A.	INTERNAL CREDIT (In-House Financing):

Closed-End Credit Sales			$ ________________________
Open-End Credit Sales (Revolving Credit)	$ ________________________
Leases						$ ________________________
For Rent-to-Own (gross rental receipts)	$ ________________________

B.	ASSIGNED CREDIT
(From #11 – if applicable):			$ ________________________

TOTAL VOLUME (12A + 12B)		$ ________________________
---------------------------------------------------------------------------------------------------------

13.	 FEES DUE:

A.	VOLUME FEE (See Schedule Below)		$ _________________________
B.	ANNUAL NOTIFICATION FEE (Main Office)	$ ___________20.00__________
C.	BRANCH FEE ($10 Each Additional Location)	$ _________________________
D.	TOTAL FEES DUE (Sum of A, B & C)		$ _________________________
I hereby certify that the statements in the foregoing report are true and correct to the best of my knowledge and belief.

Dated at ___________________ this _________________day of _________________, _________

							_______________________________________
							Signature

							By: ___________________________________
						Name Typed or Printed Legibly

Title: __________________________________

RETURN WITH PROPER FEES TO:

Bureau of Consumer Credit Protection, #35 State House Station, Augusta, ME  04333-0035

ALL CHECKS MUST BE MADE PAYABLE TO “TREASURER, STATE OF MAINE”
Maine law (5 M.R.S.A. §130) requires assessment of $20 for any check returned for insufficient funds.

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) is public information.  Other licensing records to which this information may later be transferred are also considered public records.  Where permitted by law, your name, license number, mailing address and other information listed on this application may be posted on the State’s website.

SCHEDULE OF FEES
USE TOTAL VOLUME FROM LINE 13

VOLUME AMOUNT		FEE				VOLUME AMOUNT		FEE

$           1 TO $100,000 - - - - - - - - - - - $ 25				$500,001 TO $600,000 - - - - - - - - - - - $150
$100,001 TO $200,000 - - - - - - - - - - - $ 50				$600,001 TO $700,000 - - - - - - - - - - - $175
$200,001 TO $300,000 - - - - - - - - - - - $ 75				$700,001 TO $800,000 - - - - - - - - - - - $200
$300,001 TO $400,000 - - - - - - - - - - - $100				$800,001 TO $900,000 - - - - - - - - - - - $225
$400,001 TO $500,000 - - - - - - - - - - - $125				$900,001 TO $1,000,000 - - - - - - - - - -$250*

*If your volume was in excess of $1,000,000 you can readily calculate the fee by extending the schedule.