Kansas Credit Notification
KANSAS STATE BANK COMMISSIONER
CONSUMER AND MORTGAGE LENDING DIVISION
700 SW Jackson Street, Suite 300
Topeka, KS 66603
-- 2017 Renewal -Standard Form
Pursuant to the Kansas Uniform Consumer Credit Code (K.S.A. 16a-1-101 et seq.), all persons engaged in
making Consumer Credit Sales, Leases and/or Loans (as defined in K.S.A. 16a-1-301) and Assignees of such
transactions are required to file a Credit Notification form and pay prescribed fees to the Office of the State Bank
th
Commissioner (OSBC) on or before April 30 of each year.
INSTRUCTIONS:
1. COMPLETE AND RETURN this form by APRIL 30, 2017. Mail the form along with any associated payment to the
address listed above. If you have any questions before proceeding, please contact the OSBC at (785) 296-1378 or
send an email to [email protected].
*Legal Name:
*Registration Number:
NOT.
Trade Names, or D/B/A (if applicable):
*Street Address:
*City:
*State:
*Zip Code:
Mailing Address or P.O. Box (if used):
City:
State:
Zip Code:
*Required field.
A. COMPANY LOCATIONS
A
If the company operates in locations other than the main location above, complete
A1
Attachment A on page 3.
Enter total number of business locations:
B. CREDIT TRANSACTIONS ASSIGNED/SOLD
B
Did the company assign/sell KANSAS credit contracts to others during calendar year 2016?
If “No,” proceed to Section
☐ No ☐ Yes
C. If “Yes,” complete Attachment B on page 4. Then, complete the table below.
B1 Total dollar ($) amount of all assigned transactions to
$
B2 DIVIDE Line B1 by 100,000:
#
NON-FILERS (see “No” answers on Attachment B):
B3
ROUND Line B2 up to nearest whole number:
(Examples: 0.42 = 1 -or- 22.15 = 23)
B4 MULTIPLY Line B3 by $5.00 (to figure fee):
#
$
Have you stopped Kansas credit business recently?
If the company no longer engages in Kansas consumer credit activities and considers itself no longer subject to the
Credit Notification requirements, the company’s registration must be surrendered in writing. Provide an explanation
below including the date operations/activity ceased and complete Section E, page 2. Return the form via email to
[email protected]. No fees are due if the registration is not being renewed.
KANSAS CREDIT NOTIFICATION, 2017 RENEWAL | Page 1 of 4
NOT_REN_STANDARD
Due Date: 04/30/2017
Rev. 3/2017
C. CREDIT TRANSACTIONS OUTSTANDING (NON-MORTGAGE)
Company collected* payments from a buyer/borrower, held CONSUMER credit accounts excluding home loans.
(aka: “Buy here, Pay here” – “Sales Finance” – “Holds Servicing Rights”)
*Indirect collection included
C
☐ No ☐ Yes
If “Yes,” complete the table below. Then, proceed to Section D.
Did the company have any outstanding Kansas credit accounts as described above?
If “No,” continue to Section
D.
List the month-ending balances on all KANSAS consumer credit transactions for calendar year 2016, excluding
home loans. For each month, list the unpaid balances that were outstanding on the final day of the month to
compute an average annual amount. (For help, see: http://www.osbckansas.org/cml/applications/notification.pdf)
Jan 31:
May 31:
Sep 30:
Feb 28/29:
Jun 30:
Oct 31:
Mar 31:
Jul 31:
Nov 30:
Apr 30:
Aug 31:
Dec 31:
C1
C2
TOTAL of all amounts above:
$
DIVIDE Line C1 by 12 (AVERAGE BAL.):
$
C3
DIVIDE Line C2 by 100,000:
#
C4
ROUND Line C3 up to nearest whole number: #
C5
MULTIPLY Line C4 by $10.00:
(Examples: 0.42 = 1 -or- 22.15 = 23)
$
D. FEE SUMMARY
NOTE: Complete this form using Adobe Reader (PDF) to generate the below figures automatically, based
on the information entered in the other sections.
D1 ANNUAL FEE: Number of business locations Line A1:
X
$25 =
$
D2 ASSIGNMENTS FEE: For assignments to NON-FILERS from Line B4
$
D3 VOLUME FEE: For average unpaid balances from Line C5
$
D4 TOTAL FEES PAYABLE: ADD Lines D1, D2, & D3
$
E. CERTIFICATION AND SIGNATURE
The following section should be completed by an Owner or Authorized Representative of the Registrant.
To certify your renewal, read the below statements, complete the required information, and provide a signature in the
area below. Send this form along with any applicable fees to the OSBC (mailing address listed on page 1).
I hereby certify that the information contained in this renewal form is accurate and true to the best of my knowledge and
that all required information and fees have been reported. Further, I understand that failure to file a complete and
accurate credit notification may result in criminal and/or civil penalties in accordance with K.S.A. 16a-1-101 et seq.
*Type Your Full Name:
*Date:
*Signature:
*Phone Number:
* Email Address:
*Required field.
NOT_REN_STANDARD
KANSAS CREDIT NOTIFICATION, 2017 RENEWAL | Page 2 of 4
Due Date: 04/30/2017
NOT.
Rev. 3/2017
Back to Section A, Pg. 1
ATTACHMENT A
Business Locations
List below all locations owned/leased and operated by the company to engage in Kansas credit activities. Do not
include locations occupied/managed by other sellers/creditors. Enter the total # of locations on Line A1, page 1.
Location Trade Name
Street Address
*To add more fields, duplicate this page manually.
City
Zip
Once completed, proceed to Section B.
KANSAS CREDIT NOTIFICATION, 2017 RENEWAL | Page 3 of 4
NOT_REN_STANDARD
State
Due Date: 04/30/2017
NOT.
Rev. 3/2017
Back to Section B, Pg. 1
ATTACHMENT B
Contracts Assigned/Sold
List below all assignees, the volume of contracts assigned/sold during calendar year 2016, and indicate whether
the assignee files notification. Visit: http://www.osbckansas.org/lookup/Active_Notifications.pdf to determine an
assignee’s filing status. The list is sorted alphabetically by the company name and includes d/b/a names. To search
the list, use the Find feature ("CTRL+F") available in your PDF reader.
Assignee
Company Name
Street Address
City, State, Zip
No. of
Contracts
Dollar Amt. Has Assignee
Assigned
Filed in KS?
☐ No ☐ Yes
☐ No ☐ Yes
☐ No ☐ Yes
☐ No ☐ Yes
☐ No ☐ Yes
☐ No ☐ Yes
☐ No ☐ Yes
☐ No ☐ Yes
☐ No ☐ Yes
☐ No ☐ Yes
☐ No ☐ Yes
☐ No ☐ Yes
☐ No ☐ Yes
☐ No ☐ Yes
☐ No ☐ Yes
*To add more fields, duplicate this page manually or include a separate listing.
Once completed, return to Section B.
Total to Non-Filers:
KANSAS CREDIT NOTIFICATION, 2017 RENEWAL | Page 4 of 4
NOT_REN_STANDARD
Due Date: 04/30/2017
$0
NOT.
Rev. 3/2017