STATE OF ILLINOIS
Department of Financial and Professional Regulation
Division of Banking
Notice of Establishment or Ownership of Cash Dispensing Terminal (s)
Section 30 of the Electronic Funds Transfer Act, 205 ILCS 616/30(B), requires that a person
other than a financial institution or an affiliate of a financial institution may establish, in whole or
in part, a cash dispensing terminal at which an interchange transaction may be performed,
provided that the terminal does not accept deposits of funds into an account, and provided that
the person establishing or owning the terminal shall file a notice of establishment or ownership of
a terminal with the Secretary of the Department of Financial and Professional Regulation within
60 days of acquisition or establishment and once per calendar year.
The completed registration form should be sent to:
Illinois Department of Financial and Professional Regulation
Division of Banking - Compliance Reporting Section
320 West Washington Street
Springfield, Illinois 62786
The completion of these forms is required. Failure to file the required forms with the Secretary
within 60 days of the establishment or acquisition of an ownership interest in the terminal or
annual renewal period may result in a civil monetary penalty. Annual registration is required by
owners of Non-financial ATM terminal(s). New registrants are required to provide information on
all ATM terminals. Information on registered terminals may be viewed on the Department web
site at
http://www.obrelookupclear.state.il.us/default.asp?Division=11&Profession=156&status=3.
Completion instructions for this form and the Terminal Spreadsheet are included on Page 2 of
this document. It is important to note all instructions or the form(s) may be rejected for
correction or omissions of information.
Questions concerning the completion of this form may be addressed to the Division of Banking
at (217) 782-6500 or by electronic mail at [email protected].
IL505-0326 (03/2012)
All registration form entries (Notice of Establishment or Ownership of Cash Dispensing
Terminals) must be printed or typed, provide the relevant information requested as responses such
as, “see above”, “see below”, “same” or “not applicable or NA” are not acceptable, and must be
legible.
Blank
registration
forms
can
be
found
on
our
website
at
http://www.idfpr.com/Banks/CBT/FORMS/atm-rg-f.doc, must be signed and mailed, scanned or
faxed to (217) 557-0330. If you have more than one terminal or the terminal is located at a
different location than the business, you must submit an electronic version of a spreadsheet.
Terminal Spreadsheets must be submitted electronically in the prescribed Excel format to
[email protected] and will not be accepted in typed or handwritten form. The electronic
spreadsheet for listing multiple ATM terminals can be found on our website at
http://www.idfpr.com/Banks/CBT/FORMS/TermRegistration.xls.
Please be advised that after March 15, 2012, your ATM Terminals must be compliant with
the ADA (Americans with Disabilities Act).
These requirements can be found at
http://www.ada.gov/regs2010/2010ADAStandards/2010ADAstandards.htm#pgfId-1010669
in
Section 700. If you have any questions regarding the Federally required modifications or
adaptations to your ATM Machines, please contact your ATM supplier or vendor. Failure to comply
with these ADA requirements and standards can result in fines from $55,000 for the first offense
and $110,000 to the second and subsequent offense(s) (per machine owned), in additional to
punitive damages and attorney’s fees.
Instructions for
“Notice of Establishment or Ownership of Cash DispensingTerminal(s)”
Form:
ATM/Business Name:
Name under which you want the ATM registered.
Name of Owner(s):
You may list more than one, but our system will only print one name when
you receive your annual renewal form.
8-Digit SOS Certificate Number:
This is the 8-digit number assigned to you by the Illinois Secretary of
State’s Office under which you have registered your business with their
Department. It is a Certificate of Good Standing to conduct legal business
in the State of Illinois.
Number of ATM’s
Total number of ATM’s owned by your Business
If the Number is one (1), you need to enter the terminal serial number in the
Terminal Information Section on the Registration form.
If the number is more than one (> 1), you need to provide an Excel
spreadsheet to the Department listing all terminals and their serial numbers.
This spreadsheet must be e-mailed to the Department at
[email protected].
Principal Contact person
This is the person in charge of the Machine and to be contacted if there is a
question regarding the registration.
Consumer Contact person
This is the person to be contacted if a consumer/user has a complaint.
Terminal information
See Number of ATM’s (above). The form will be rejected without complete
information.
Signature
The form must be signed. The form will be rejected without a valid
signature.
IL505-0326 (03/2012)
STATE OF ILLINOIS
Department of Financial and Professional Regulation
Division of Banking
Notice of Establishment or Ownership of Cash Dispensing Terminal(s)
Owner(s) of Terminal
Please Print or Type
Percent of Ownership
ATM/Business Name:
8-Digit SOS #
Name(s) of Owner(s):
Number of ATMs:
ATM/Business Address:
Business Phone Number: (
City/State/Zip Code:
Business Fax Number: (
ATM/Business E-Mail:
Business web site:
%
)
)
Principal Contact Person
Title:
Name:
Home Street Address:
City:
Home Phone: (
State:
)
Zip Code:
Fax: (
)
Email:
Contact Information for Consumers
Name:
Title:
Street Address:
City:
Home Phone: (
State:
)
Fax: (
Zip Code:
)
Email:
Terminal Information: If you own a single terminal AND it is located at the same location as the
Business Name or address of Owner(s), provide the following: Terminal Serial Number
If you own more than one terminal or the terminal is not located at the address listed above, please
submit the terminal information via email using an Excel spreadsheet to [email protected]. Handwritten
spreadsheets will not be accepted. Your submission must be in EXCEL format as required by the
Department and can be found on our website at http://www.idfpr.com/Banks/CBT/forms/TermRegistration.xls.
CERTIFICATION
I certify that the information provided on this form is true and complete to the best of my knowledge and belief.
Signature:
Title:
Printed Name:
Date:
Phone #: (
)
In accordance with the Electronic Fund Transfer Act (205 ILCS 616/30B), failure to file this form on an annual
basis by the owner(s) of a Non-Financial ATM terminal(s) may be subject to civil penalties of up to $1,000 for the
first failure to comply and up to $10,000 for the second and each subsequent failure to comply with this Act.
IL505-0326 (03/2012)