Money Service Business Application For Currency Exchange Texas

CORP-M01 [09/23]

Money Service Business Application

For Currency Exchange

Texas Department of Banking

MONEY SERVICES BUSINESS LICENSE APPLICATION FOR CURRENCY EXCHANGE

Table of Contents

NOTICE TO APPLICANTS ..................................................................................................................... i

MONEY SERVICES BUSINESS LICENSE APPLICATION ............................................................... 1

REQUIRED EXHIBITS TO APPLICATION ......................................................................................... 6

EXHIBIT A – BUSINESS PLAN ........................................................................................................ 6

EXHIBIT B –FINANCIAL STATEMENTS ....................................................................................... 6

EXHIBIT C – SUPPLEMENTAL FORMS ......................................................................................... 7

EXHIBIT D – ORGANIZATIONAL STRUCTURE & CORPORATE DOCUMENTS.................... 7

EXHIBIT E – CERTIFICATE OF GOOD STANDING ..................................................................... 7

EXHIBIT F – ASSUMED NAME FILINGS ....................................................................................... 7

EXHIBIT G – SECURITY ................................................................................................................... 8

EXHIBIT H – CLEARING ACCOUNTS ............................................................................................ 9

EXHIBIT I – ACH FORM ................................................................................................................... 9

EXHIBIT J – CERTIFICATION OF REGULATORY COMPLIANCE ............................................ 9

APPENDICES ........................................................................................................................................ 12

APPENDIX A – REQUIRED SUPPLEMENTAL FORMS .............................................................. 13

FINGERPRINT INSTRUCTIONS ............................................................................................. 14

SEARCH FIRM REPORT INSTRUCTIONS ........................................................................... 14

STATEMENT OF PERSONAL HISTORY .............................................................................. 15

AUTHORITY TO RELEASE INFORMATION ...................................................................... 19

PERSONAL FINANCIAL STATEMENT ................................................................................. 20

APPENDIX C – SECURITY FORMS ............................................................................................... 26

MONEY SERVICES BOND ....................................................................................................... 27

DEPOSIT IN LIEU OF SURETY BOND .................................................................................. 29

APPENDIX D - ACH FORM............................................................................................................. 33

MONEY SERVICES BUSINESS LICENSE APPLICATION FOR CURRENCY EXCHANGE

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NOTICE TO APPLICANTS

FOR CURRENCY EXCHANGE

Texas Finance Code, Chapter 152 (Chapter 152), generally requires a person or business to have

a license to engage in the money services business in Texas. There are two types of Money

Services Business licenses and separate applications for each type. A person or business that

engages only in the currency exchange business must have a currency exchange license. Please

note that the application for a money transmission license is a separate application form.

Certain requirements for a money transmission license are different from the requirements for a

currency exchange license. Please read Chapter 152 to determine if you are engaged in a

business that requires a license and what kind of license you need. Refer particularly to Sections

152.003 (definitions), 152.004 (exemptions), and 152.101 (money transmission license required)

of the Code. Licenses do not expire.

The filing of an Application for a Money Services Business (Application) for a new license, or

requesting an Application or otherwise corresponding with the Texas Department of Banking

about the need for a license or about your Application, does not authorize you to engage in

business activities that require a license under Chapter 152. If you are operating without the

required license, you are violating Chapter 152 and you are subject to enforcement action and

penalties.

To apply for a Money Services Business license, you must file an Application with the Texas

Department of Banking. The Application for a currency exchange license consists of the forms,

schedules, exhibits and attachments that are attached to or follow this Notice.

The filing fee of $5,000 must accompany your application. Your check should be made payable

to the Texas Department of Banking. The filing fee is non-refundable. In addition, the

Department may charge investigations fees for processing applications that take longer than

normal or where an onsite investigation is necessary. You will be notified before any

investigation fees are imposed.

If you do not submit the filing fee at the same time you submit your application, your

application will be returned.

The Application must be fully completed and all of the required information must be provided.

You must respond to each question, even if the answer is “None” or Not Applicable”. Be sure

to:

1. Provide complete addresses, including zip codes.

2. Sign each form where required.

3. Have signatures notarized as required.

4. Cross-check the information BEFORE you submit the Application to insure accuracy

and consistency in the information provided.

In accordance with the USA PATRIOT Act of 2001 and the Department of Treasury’s Title 31

CFR Chapter X, pertaining to anti-money laundering programs for the Money Services

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Businesses, each applicant must be aware of the requirements of the law and its implementation

deadlines. Money services businesses currently established must be in compliance with these

requirements, including a current registration with Financial Crimes Enforcement Network

(FinCEN), a division of the U.S. Department of Treasury, www.fincen.gov as a money services

business.

Please direct any questions regarding a Money Services Business Application or a proposed new

license to the Texas Department of Banking, Corporate Activities Division, at (512) 475-1342 or

corpmail@dob.texas.gov.

SECURITY: Security is the term used in Chapter 152 to describe the surety bond or deposit

required under §§152.353 for a currency exchange license. The required security for a currency

exchange license is $2,500 if the license conducts business with person located in this state

exclusively at one or more physical locations through in-person, contemporaneous transactions.

Otherwise, the security required for a currency exchange license is the greater of $2,500 or one

percent of the licensee’s total dollar volume of currency exchange business in this state for the

preceding year not to exceed the maximum security of $1 million.

Please carefully review §152.353 and §152.354 for details about the security requirements.

NET WORTH: An Applicant that intends to engage only in the currency exchange business

and that applies for a Currency Exchange License must submit a current financial statement that

demonstrates the Applicant’s solvency. The financial statement must be certified to by a

responsible officer. The required financial statements must be in English and denominated in

U.S. Dollars.

BACKGROUND CHECKS: Extensive background checks are conducted on each Applicant as

well as each person in control of the Applicant “Control Person” and Key Individuals. See

§152.003 for definitions and Appendix A-Supplemental Forms for clarification. These checks

include law enforcement agencies, credit reports, and other regulators.

Control Persons and Key Individuals who have resided outside the U.S. at any time in the

preceding 10 years, must have an investigative background report prepared by an acceptable

search firm. The investigation report must be submitted directly to the Department with a

copy of the report provided at the time of submission of the application. Refer to Search

Firm Report instructions in Appendix A. Contact the Corporate Activities Division for additional

information.

CONFIDENTIALITY: Review Chapter 152 of the Texas Finance Code thoroughly prior to

completing the application form. If you have any questions please contact the Corporate

Activities Division at (512) 475-1294. Completed application forms should be mailed to:

Texas Department of Banking

Corporate Activities Division

2601 North Lamar Blvd.

Austin, TX 78705-4294

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Information submitted in connection with the application may be subject to disclosure under the

Open Records Act and Chapter 152 of the Code. Confidential information should be clearly

marked when submitted.

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MONEY SERVICES BUSINESS LICENSE APPLICATION

FOR CURRENCY EXCHANGE

This application must be completed for entities seeking to engage in the business of

currency exchange. Refer to Chapter 152 of the Texas Finance Code (TFC)

1. Full legal name of the Applicant and Federal Taxpayer Identification number.

__________________________________________________________________

2. a) Indicate the form of the Applicant’s legal organization, e.g. corporation, LLC,

limited partnership, sole proprietorship. _______________________________

b) If the Applicant is not a sole proprietorship, and is owned 25% or more by any

corporate entity, provide a chart detailing the structure of the organization.

3. Any DBA or assumed name to be used in Texas, if applicable.

__________________________________________________________________

4. Primary Business Location (street address, city, state, zip code).

__________________________________________________________________

5. Mailing address of Applicant:

_____________________________ ______________________________

Street Address P.O. Box

_____________________________ ______________________________

City, State, Zip Code City, State, Zip Code

6. Individual who is to serve as primary contact for questions on the application.

Name: ________________________________________

Title: _________________________________________

Telephone Number: ______________________________

Email Address: __________________________________

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7. Anticipated number of locations to be established in Texas by the Applicant during the

first year of operations _____. Service is to be provided through (indicate the number of

all that apply):

____Company Owned Outlets ____Subsidiaries or Affiliates

____Authorized Delegate ____Internet

____Other (explain)

8. a) Products or services to be offered directly to Texas citizens under this license:

____Currency Exchange

b) Products or services to be offered as an authorized delegate (mark all that apply):

Product or Service

Name of Licensee

Money Transmission

Checks

Travelers Checks

Bill Pay

Currency Transportation

Money Orders

Drafts

Prepaid Access Products

Gift Cards

Other (explain)

9. Identify all websites operated by the Applicant.

__________________________________________________________________

10. Provide the name, title, telephone number, and email addresses for each of the following

individuals:

a) President

Name: ________________________________________

Title: _________________________________________

Telephone Number: ______________________________

Facsimile Number: _______________________________

Email Address: __________________________________

b) Chief Financial Officer

Name: ________________________________________

Title: _________________________________________

Telephone Number: ______________________________

Email Address: __________________________________

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c) Chief Compliance Officer

Name: ________________________________________

Title: _________________________________________

Telephone Number: ______________________________

Email Address: __________________________________

d) Individual who is to serve as primary regulatory contact with the Department if the license is

granted

Name: ________________________________________

Title: _________________________________________

Telephone Number: ______________________________

Email Address: __________________________________

11. Identify shareholders who own or control 10% or more of the Applicant. Include the name,

address, shares owned or controlled, number and percent of outstanding. If the Applicant is a

limited partnership, provide information on the general partner, directors, managers, control

shareholders, executive officers or responsible individuals of the general partner.

12. List all individuals who serve on the Board of Directors or Board of Managers or otherwise

control or direct the activities of the Applicant.

13. List the names and title of all Key Individuals (not already included in number 10 above). See

§152.003(17) for definition of Key Individual which include executive officers, managers,

directors, or trustees.

14. Attach evidence of current registration with Financial Crimes Enforcement Network (FinCEN)

as an MSB. Forms can be found at the FinCEN’s website, www.fincen.gov.

15. Describe in detail any pending or any outstanding enforcement actions taken by a regulatory

agency against the Applicant, its affiliates, and any principals of the Applicant, and any

judgments outstanding against the Applicant.

16. Does the Applicant owe the department a delinquent fee, assessment, administrative penalty or

other amount imposed under Chapter 152 or a rule or Order issued under Chapter 152?

17. Is the applicant currently transacting business in Texas and/or with Texas customers?

(a) Indicate how long the Applicant has been conducting business in Texas and

(a) Provide the volume of business in Texas in dollars and number of transactions per year.

18. If the Applicant has been operating in Texas as an agent for another licensee, indicate how long

the Applicant has been an agent, and provide a copy of the contract with that licensee.

19. Provide a listing of all the states in which you are currently operating.

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20. Provide a listing of the other states or jurisdictions in which a license or similar authorization is

sought, has been granted, or denied to the Applicant or its affiliates, to engage in the money

services business. Include:

(a) The state, year licensed, type of license held, the agency issuing the license, the name,

phone number and email address of the primary regulatory contact and date of last exam.

(a) Indicate the volume of business conducted in each jurisdiction in dollars and in number

of transactions.

(a) List any license revocations, suspension, or disciplinary action taken against the applicant

in any other state.

CERTIFICATION

I hereby certify that:

1. I am authorized to file this application, and that all information submitted to the Commissioner in

connection with this application including the forms, schedules, exhibits, attachments and any

related correspondence is true, and correct, to the best of my knowledge and belief.

2. On behalf of the Applicant, I certify that the Applicant and each principal of, person in control

of, and proposed responsible individual of the Applicant: (1) is familiar with and agrees to fully

comply with all applicable state and federal laws and regulations pertaining to the applicant’s

proposed money services business, including TFC Chapters 152 and 271, relevant provisions of

the Bank Secrecy Act, and the USA PATRIOT ACT; (2) has not within the preceding three years

knowingly failed to file or evaded the obligation to file a report, including a currency transaction

or suspicious activity report required by the Bank Secrecy Act, the USA PATRIOT ACT, or

Chapter 271; and (3) has not knowingly accepted money for transmission or exchange in which a

portion of the money was derived from an illegal transaction or activity.

3. The Applicant is not indebted to any local, state, or federal government or political subdivision

of the government for delinquent taxes, fines, penalties or fees.

4. To the best of my knowledge and belief, all information necessary for the Commissioner to make

an informed decision is contained herein. In addition, I agree to notify the Commissioner if the

facts described in the filing materials change prior to issuance of the license.

A person commits a felony offense if the person intentionally makes an untrue statement of

material fact in this application.

_____________________________ by ____________________________________

(Applicant) (Signature)

____________________________________

(Printed or Typed Name)

____________________________________

(Title)

MONEY SERVICES BUSINESS LICENSE APPLICATION FOR CURRENCY EXCHANGE

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STATE OF __________________

COUNTY OF ________________

On this _______ day of __________, 20___, before me, a Notary Public in and for said County,

of said State, personally appeared: _____________________________________

known to me to be the person named in, and who executed the foregoing form and made oath

that the statements and representations set forth therein are true to the best of his/her knowledge

and belief.

_________________________________

(Notary Public)

MONEY SERVICES BUSINESS LICENSE APPLICATION FOR CURRENCY EXCHANGE

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REQUIRED EXHIBITS TO APPLICATION

The following exhibits are REQUIRED of every Applicant. Exhibits must be clearly marked.

All information requested in each exhibit should be provided to ensure timely processing of

the application.

EXHIBIT A – BUSINESS PLAN

Attach a copy of the business plan or a detailed summary of the business plan. The business plan

must describe in detail the following:

1. Method and types of operations including activities and types.

2. Location of operations and outlets, number and type, at the end of each of the first two

years of operation in Texas.

3. Projections for the first two years showing the anticipated growth in volume and in

number of transactions during each of the first two years of operations in Texas.

EXHIBIT B –FINANCIAL STATEMENTS

1. Include the most recent current fiscal year-end financial statement certified by a

responsible officer which may be prepared by an auditor or other qualified personnel in

accordance with (a), (b), and (c), and which demonstrates solvency. Such statement must

also contain certification language such as: “I hereby certify under penalty of perjury that

the information contained in this confidential financial report, including supplemental

schedules, has been carefully examined by me and is correct and complete and further

acknowledge that there are no misrepresentation or omissions of material facts.”

a) Constructed in accordance with generally accepted accounting principles.

b) Including:

(1) Balance Sheet.

(2) Statement of Income and Retained Earnings.

c) If the Applicant’s fiscal year ends 120 or more days prior to the date of

application, then the Applicant must forward the aforementioned certified

financial statements covering the most recent fiscal year; and, the interim

financial statements covering the most recent accounting period within 90 days of

the date of application. The interim financial statement must also be prepared by

the auditor or other qualified party, and certified by a responsible officer.

2. Publicly Traded Entities:

• If the applicant is a publicly traded corporation, upload a copy of the most recent

report (10-K or 10-Q) filed with the United States Securities and Exchange

Commission under Section 13, Securities Exchange Act of 1934 (15 U.S.C.

Section 78m).

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• If the applicant is a wholly owned subsidiary of a corporation publicly traded in

the United States, a copy of audited financial statements for the parent corporation

for the most recent fiscal year or a copy of the parent corporation’s most recent

report filed (10-K or 10-Q) under Section 13, Securities Exchange Act of 1934

(15 U.S.C. Section 78m).

EXHIBIT C – SUPPLEMENTAL FORMS

A number of forms are considered supplemental forms and must also be included with the

application. Refer to Appendix A of this application to determine which forms must be completed

and by whom.

EXHIBIT D – ORGANIZATIONAL STRUCTURE & CORPORATE DOCUMENTS

1. Provide a brief description of the structure or organization of the applicant, including any

parent entity or subsidiary of the applicant, and whether any parent entity or subsidiary is

publicly traded.

2. Provide a list of any criminal convictions and material litigation in which a person in

control of the applicant that is not an individual has been involved in the 10-year period

preceding the submission of the application.

3. Provide a copy of the filed Applicant’s Certificate of Formation or other organizing

documents, as well as those of any other entity that controls the Applicant, and evidence

of registration with the Texas Secretary of State, if the Applicant is not a Texas entity.

*NOTE TO CORPORATIONS: If the Applicant is applying as a Texas corporation, limited

liability company or limited partnership, or if the Applicant is a foreign corporation (e.g., a

corporation not incorporated in Texas) seeking to register to do business in Texas, contact:

Texas Secretary of State

Corporations Section

P.O. Box 13697

Austin, Texas 78711-3697

512/463-5555

4. Does the applicant have a registered agent? If yes, provide the name and address of the

applicant’s registered agent.

EXHIBIT E – CERTIFICATE OF GOOD STANDING

A Certificate of Good Standing in the state or country of incorporation and a Franchise Tax

Account Status from the Texas Office of Comptroller of Public Accounts, if the Applicant is a

corporation. See Appendix B for NOTICE TO ALL CORPORATIONS.

EXHIBIT F – ASSUMED NAME FILINGS

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Copies of the assumed name filings, as applicable, filed with the Secretary of State and with the

clerk of court in the counties where the Applicant proposes to do business, if a name other than

the legal name of the Applicant is to be used in Texas.

EXHIBIT G – SECURITY

Acceptable security may be in the form of a surety bond issued by a company authorized to do

business in Texas or deposit in lieu of bond by an acceptable financial institution in the amount

required by § 152.353. The original document must be submitted with the application. Refer to

appendix C of this application for forms.

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EXHIBIT H – CLEARING ACCOUNTS

Provide a letter from the bank’s compliance officer, for each clearing account to be utilized in

the business, indicating that the bank is aware that the applicant accounts are being used to

facilitate the operation of a money services business. The letter should also indicate if there are

any restrictions/conditions placed on this account by the Bank before they allow the applicant to

use it for money services business activity (i.e. .license granted, etc.).

The letter must also include the following information:

• Name of Financial Institution

• Street Address

• Contact Person

• Phone and fax numbers

• Account type

• Account number

EXHIBIT I – ACH FORM

This form must be submitted at the time of application and must be signed by the applicant.

Refer to Appendix D of this application for ACH form. Please note annual license fees and

assessment fees owed to the Department pursuant to §33.27 of the Texas Administrative Code

may only be paid via ACH debit. No other method of payment is accepted by the Department

EXHIBIT J – CERTIFICATION OF REGULATORY COMPLIANCE

A signed Certification of Regulatory Compliance (below) with all required attachments

provided.

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EXHIBIT J

CERTIFICATION OF REGULATORY COMPLIANCE

As evidenced by our signatures, we duly appointed principals of (name of

applicant)__________________________________________, do hereby certify the

following:

1. Applicant and each principal of, person in control of, and proposed responsible individual

of the Applicant is familiar with and agrees to fully comply with all applicable state and

federal laws and regulations pertaining to the applicant’s proposed money services

business, including Chapters 152, and 271 of the Texas Finance Code, Chapter 33 of the

Texas Administrative Code and relevant provisions of the Bank Secrecy Act, and the

USA PATRIOT ACT.

2. The applicant will have in a place a formally adopted and fully implemented written anti-

money laundering program that complies with Title 31 Code of Federal Regulations

(CFR) Chapter 1022.210. Such program shall include a risk assessment and procedures

employed to “Know your customer”. [A copy of the written anti-money laundering

program and risk assessment must be submitted with this exhibit and marked as

Exhibit J-1]

3. The applicant will ensure that the methods to be utilized to inform customers about their

rights to file a complaint with the Texas Department of Banking will comply with the

requirements of Texas Administrative Code Section 33.51. [A copy of the consumer

complaint notice be submitted with this exhibit and marked as Exhibit J-2]

4. The applicant will prepare and maintain records and reports in accordance with the

requirements of Texas Finance Code Sections 152.202 and 152.207, and Section 33.31

Texas Administrative Code.

5. The applicant acknowledges that each authorized delegate must prominently display a

notice that indicates that the person is an authorized delegate of the applicant in

accordance with Texas Administrative Code Section 33.51(f). [A copy of the authorized

delegate affiliation notice must be submitted with this exhibit and marked as

Exhibit J-3]

6. The contract utilized in the business with authorized delegates will conform to the

requirements of Texas Finance Code Section 152.252(d). A copy of the authorized

delegate agreement must be submitted with this exhibit and marked as Exhibit J-4]

7. The applicant will take all measures to ensure that customer information is protected and

will have in place procedures to adhere to the Gramm-Leach-Bliley Act (Right to

Financial Privacy Act).

8. The applicant will adopt and implement procedures pertaining to Office of Foreign Asset

Control (OFAC) to ensure compliance with regulations prohibiting transactions with

persons or entities on the OFAC Specially Designated Nationals List.

9. The applicant will have in place procedures to ensure compliance with state

recordkeeping requirements including Texas Administrative Code Sections 33.31 and

33.33 federal recordkeeping requirements including 31 CFR §1022.410.

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10. The applicant shall ensure that receipts provided in connection with the currency

exchange activity are in compliance with Texas Administrative Code Section 33.33. [A

sample copy of the currency exchange receipt must be submitted with this exhibit

and marked as Exhibit J-5]

11. The applicant will have in place an information system which is suitable to the type of

business in which the applicant will engage and the security hardware, software, and

procedures will be sufficient to protect the applicant from unauthorized tampering or

access; and as appropriate, will be integrated with the anti-money laundering program

and compliance procedures.

12. If the person in control of the applicant is not an individual, the person in control of the

applicant has not had any criminal convictions and has not been involved in any material

litigation withing the 10-year period preceding the submission of the application. [If any

of this statement is false, submit a list of convictions and material litigation with this

exhibit marked as Exhibit J-6]

At a minimum, this certification must be signed by the President, Chief Financial

Officer, and the Chief Compliance Officer.

We, the undersigned principals of ___________________________________(applicant) do

hereby acknowledge that we have received and read this Certificate of Regulatory Compliance

and further acknowledge that it is not inclusive of regulatory requirements and/or best business

practices.

_____________________________ Title_____________________________

(Printed Name)

______________________________Date__________

(Signature)

_____________________________ Title_____________________________

(Printed Name)

______________________________Date__________

(Signature)

_____________________________ Title_____________________________

(Printed Name)

______________________________Date__________

(Signature)

(use additional pages if needed)

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APPENDICES

The attached forms and instructions are part of the application. The forms must be

completed as indicated and included in the application as part of the exhibits indicated

above.

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APPENDIX A – REQUIRED SUPPLEMENTAL FORMS

Refer to the instructions below to determine which of these supplemental forms must be completed. Unless

indicated to the contrary, all requirements for supplemental forms apply only to individuals.

Key Individuals

The definition of Key Individual per Texas Finance Code Section 152.003(17) includes an individual who is

ultimately responsible for establishing or directing policies and procedures of a money services licensee,

including an executive officer, manager, director, or trustee. Each Key Individual must submit:

1. Authority to Release Information

2. Statement of Personal History

3. Fingerprints – (See Fingerprint Instructions below)

4. Search Firm Report (See Search Firm Report Instructions below)

Control Persons and Legal Entities

• Control Persons - A “Control Person” is any person who has control of the applicant. See Section

152.003(8) of the Code for definitions of control and Section 152.061 of the Code for definition of

presumption of control. Control Persons must submit:

1. Authority to Release Information

2. Statement of Personal History

3. Personal Financial Statement**

4. Fingerprints – (See Fingerprint Instructions below)

5. Search Firm Report (See Search Firm Report Instructions below)

• Spouse – Applicants who are individuals or wholly owned directly or indirectly by a single individual

must have spouses of the controlling owners also submit fingerprints, authority to release information

and statement of personal history.

• Legal Entities directly or indirectly controlling 50% or more of the applicant must submit a current

certified financial statement.

**Personal Financial Statements, whether required only for an individual or for an individual and spouse, may

include joint financial information for both spouses. Joint financial statements must be signed by both spouses.

Complex Organizational Structures

Supplemental form requirements for complex organizational structures will be evaluated on a case-by-case

basis. Pre-submission of the organizational chart and proposed structure may be necessary to determine the

applicability of various forms.

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FINGERPRINT INSTRUCTIONS

The collecting and submitting of fingerprints to the FBI is handled through the Texas Department of Public

Safety (DPS). They use an exclusive vendor, IdentoGo by MorphoTrust USA to gather the fingerprints.

Fingerprints, electronic or physical cards, should not be submitted to MorphoTrust prior to the Department

acknowledging receipt of your application (for new applicants) or receipt of an authority to release information

form (for current supervised, licensed or registered entities). Upon receipt of a new application the Department

will provide you with a Texas Fingerprint Service Code Form and detailed instructions so you may begin the

fingerprinting process. Please note that you may be required to resubmit fingerprints if you begin the

process with MorphoTrust prior to the Department’s acknowledgment of receipt of a new application or

authority to release information form.

Non-Texas residents and Texas residents located outside of IdentoGo’s service areas may submit physical

fingerprint cards to MorphoTrust USA’s office for electronic processing. You may have these individuals

fingerprinted by a local Law Enforcement Agency, such as a local police station, sheriff’s office or county

police department, or a private company with an expertise in fingerprinting before you submit your application

or authority to release information forms. However, these physical cards should not be submitted to

MorphoTrust until you are instructed to do so by the Department. In addition, fingerprint cards should

not be submitted directly to the Department.

Please be aware that some law enforcement agencies charge a fee for taking fingerprints. In addition, please

note the Department does not provide fingerprint cards. You must obtain your own FBI fingerprint cards.

SEARCH FIRM REPORT INSTRUCTIONS

Control Persons and Key Individuals who have resided outside the U.S. at any time in the preceding 10 years,

must have an investigative background report prepared by an acceptable search firm. The search firm report

must be prepared by an independent search firm and both the search firm and the search firm report must meet

the requirements of Section 152.105(c) of the Code. The report must be submitted directly to the Department by

the search firm.

If an individual has had such a report, which meets the specifications listed above, prepared for another

licensing agency within the past 12 months, the individual may have the investigating agency submit a copy of

that report to us. In addition to the documentation generally required, the individual would need to submit a

statement of no material change.

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STATEMENT OF PERSONAL HISTORY

Must be submitted by each Control Person, Key Individual, spouse of applicants who are individuals, and spouse

of individuals who wholly own the applicant directly or indirectly.

APPLICANT NAME: _______________________________________________________________________

Print or type all answers. If more space is needed, use the “Remarks” section and attach additional sheets if necessary.

Clearly identify each response.

A. GENERAL

Name: ____________________________________________________________________________________

(Last) (First) (Middle)

Aliases, Nicknames, and Previous Names: _____________________________________________________

Residence Address: ________________________________________________________________________

Street City State Zip Code

Business Address: ________________________________________________________________________

Street City State Zip Code

Residence Telephone: ________________________ Business Telephone: ________________________

Marital Status: ___________ If married, full name of spouse: _______________________________________

Email Address: _______________________________________________________________________

Are you a U.S. Citizen? Yes___ No___. If you were not born in the U.S. provide a copy of your naturalization

certificate or passport. If the answer is “No,” furnish complete details on a separate sheet. Include copies of documents

that will support your alien status. Include passport number, Home Country ID No., and Immigration File No., if

applicable.

Date of Birth: ___________________________ Place of Birth: _____________________________

Driver’s License Number & State of Issue: ______________________________________________________

Social Security Number: _______________________ Federal Tax ID Number: _________________

Check your position and job responsibilities with Applicant (Indicate all that apply):

Director General Partner Trustee

Manager Person in Control Responsible Individual

Executive Officer – Title: _________________________

Other (Describe): ___________________________________________________________________________

CORP-M01 [09/23] Texas Department of Banking Page 16

B. EDUCATION: (Account for all schools attended beyond 12

grade.)

Dates

Name and Address of School

Grade Completed

C. EMPLOYMENT: (List all employment for the past 10 years in chronological order.)

Dates

From: To:

Name and Address of Employer

(Include Street, City, State and Zip)

Reason

For Leaving

D. RESIDENCES: (Show all residences for the past 10 years in chronological order)

Dates

From: To:

Street and Number, City, State, and Zip

CORP-M01 [09/23] Texas Department of Banking Page 17

E. List all your occupational or professional licenses, including those surrendered, which have been issued by an agency

of ANY state, the U.S. federal government, or the government of any other country.

Type of License

Name/Address of Licensing Agency

Original Issuance Date

Expiration Date

F. List all your occupational or professional licenses that have been refused, denied, revoked, or suspended by an agency

of ANY state, the U.S. federal government, or the government of any other country.

Type of License

Name/Address of Licensing Agency

Type of Action

Date of Action

G. Have you ever been detained, held, arrested, indicted, or summoned into court as a defendant in a criminal

proceeding, or convicted, fined, imprisoned, or placed on probation, or ordered to deposit bail or collateral for the

violation of any law, ordinance, police regulation, or military regulation other than for a misdemeanor? Yes_____

No_____. If the answer is “Yes,” complete the following.

Date

Offense

Location of Offense

Disposition

H. Have you ever been granted any security clearance in connection with any employment? Yes_____ No_____. If

“Yes,” provide details. _______________________________________________________

I. Have you ever been refused bond or had a bond cancelled or revoked? Yes_____ No_____. If “Yes,” provide

details. ______________________________________________________________________

J. Have you ever been in a position which required a fidelity bond? Yes_____ No_____. If any claims were

made on the bond, give details. _____________________________________________________

K. Has an order, injunction or judgement, whether or not final, been entered against you in a civil action on account

of fraud, misrepresentation or deceit? Yes_____ No_____. If “Yes,” provide details on a separate sheet.

CORP-M01 [09/23] Texas Department of Banking Page 18

L. Have you been sued in a civil action within the last 10 years? Yes_____ No_____. If “Yes,” provide details on a

separate sheet.

M. Have you filed bankruptcy or served as a principal of an entity that filed bankruptcy within the last 10 years?

Yes_____ No_____. If “Yes,” provide details on a separate sheet.

N. Are you currently the subject of an administrative action or order issued by an administrative agency of this state,

the federal government, or any other state or territory of the United States, or the government of any other

country? Yes_____ No_____. If “Yes,” provide details on a separate sheet.

O. Do you owe delinquent taxes to any local, state, or federal government or political subdivision of the government?

Yes_____ No_____. If “Yes,” provide details on a separate sheet.

P. Do you owe the Department or any state any delinquent fees, assessments, administrative penalty, or other

amount imposed by state or federal court order? Yes_____ No_____. If “Yes,” provide details on a separate

sheet.

Q. Have you been convicted of a felony criminal offense under state or federal law, or a similar law of a foreign

country, related to deception, dishonesty, or defalcation? Yes_____ No_____. If “Yes,” provide details on a

separate sheet.

R. Have you been convicted of a felony criminal offense under state or federal law, or a similar law of a foreign

country, related to money transmission or other money services, including a reporting, recordkeeping or

registration requirement of the Bank Secrecy Act, the USA PATRIOT ACT or Chapter 271? Yes_____

No_____. If “Yes,” provide details on a separate sheet.

S. Have you been convicted of a felony offense under state or federal law, or a similar law of a foreign country,

related to money laundering, structuring, or a related financial crime, drug trafficking or terrorist funding?

Yes_____ No_____. If “Yes,” provide details on a separate sheet.

T. Have you or your spouse been convicted of a similar criminal offense to that referenced in Q – S under a similar

law of a foreign country? Yes_____ No_____. If “Yes,” provide details on a separate sheet.

U. Do you owe the Department a delinquent fee, assessment, administrative penalty or other amount imposed by

Chapter 152 or a rule or order issued under Chapter 152? Yes_____ No_____. If “Yes,” provide details on a

separate sheet.

I hereby certify under penalty of perjury that I am acting on my behalf, and that the foregoing statements are true and

correct.

Date: _______________________ Signature: ___________________________________________

Typed or Printed Name: ____________________________________

CORP-M01 [09/23] Texas Department of Banking Page 19

AUTHORITY TO RELEASE INFORMATION

Please print or type all information.

Full Name:

Alias or DBA:

Residence: ________________________________________________________________________________________

Street Address City State Zip Code

Business: __________________________________________________________

Street Address City State Zip Code

Telephone Number (Include Area Code)

Fax Number (Including Area Code)

Social Security Number or Federal Tax ID Number

Driver’s License Number/State

Date of Birth

Citizenship

DPS Number

FBI Number

* If DPS and/or FBI numbers are not known, please give the following physical description.

Race

Sex

Age

Height

Weight

Hair Color

Eye Color

This release constitutes my consent and authority for The Texas Department of Banking to examine

and obtain copies of records, statements, credit ratings and information regarding my background. I

hereby specifically authorize the release of records to The Texas Department of Banking pertaining to

the following:

Any local, state, federal, or international governmental records

Employment Information

Past experience with a regulated entity

Credit Information

Tax Records, Federal or other jurisdictions

Police and Criminal Records

This authorization is given in connection with my application filed with the Texas

Department of Banking.

(Signature) (Date)

CORP-M01 [09/23] Texas Department of Banking Page 20

PERSONAL FINANCIAL STATEMENT

Name ____________________________________

Applicant __________________________________

Statement of Financial Condition as of ___________________, 20_____ for the period

______________, ______ to ______________, ______

ASSETS

LIABILITIES AND NET

WORTH

Cash on Hand & in Banks (Schedule 1)

Notes Payable to Banks-Secured

& Unsecured (Schedule 6)

U.S. Government Securities

Notes Payable to Relatives (Schedule 6)

Accounts, Loans, &

Notes Receivable (Sch 2)

Accounts & Notes Payable to Others (Schedule 6)

Marketable Stocks

& Bonds (Schedule 3)*

Rents & Interest Due

Real Estate (Schedule 4)

Real Estate Taxes Due (Schedule 4)

Automobiles - Number ( )

Liens on Real Estate (Schedule 4)

Proprietary Interests (Schedule 5)**

Other Taxes Due

Other Assets (Itemize)***

Other Liabilities (Itemize)

TOTAL LIABILITIES

NET WORTH

TOTAL ASSETS

TOTAL LIABILITIES AND NET

WORTH

ANNUAL INCOME

CONTINGENT LIABILITIES

Salary

As Endorser or Co-Maker

Bonus & Commissions

On Leases or Contracts

Dividends & Interest

Legal Claims

Real Estate Income

Provision for Federal Income Tax

Other Income (Itemize)

Other Special Debt (Itemize)

TOTAL INCOME

TOTAL CONTINGENT

LIABILITIES

Assets pledged or hypothecated valued at $______________ are pledged to secure notes or obligations aggregating $_________________.

I have additionally endorsed, guaranteed or am contingently liable for debts of others amounting to $__________________.

CORP-M01 [09/23] Texas Department of Banking Page 21

I hereby certify under penalty of perjury that the information contained in this confidential

financial report, including supplemental schedules, has been carefully examined by me and is

correct and compete and further acknowledge that there are no misrepresentation or omissions of

material facts.

Dated and signed this _____ day of ___________________, 20____.

________________________________________

(Signature)

________________________________________

(Typed or Printed Name)

* Marketable securities are generally only those which are listed on the NY, American Stock

Exchanges and NASDAQ.

** If the stock of a company amounts to 25% or more of an individual’s net worth, financial

statements, including balance sheet, profit and loss, cash flow statements of the company

must be provided for the past year.

*** If total reflected on this line represents 10% or more of your net worth, a schedule must be

provided listing each item separately and providing a complete description, including

financial information, if appropriate.

CORP-M01 [09/23] Texas Department of Banking Page 22

SCHEDULES

Schedule 1. Banking Relations. (List all bank accounts)

Name of Financial Institution

Address

Type of

Account

Number

Balance

TOTAL

Schedule 2. Accounts, Loans, & Notes Receivable.

Name and Address of Debtor

Date

Originated

Description or

Nature of Debt

Description of

Security Held

Maturity

Date

Balance

Due

TOTAL

Schedule 3. Marketable Stock and Bonds.

Face Value Bonds

No. Stock Shares

Description

of Security

Registered in

Name of

Cost

Income Received

Last Year

If Pledged,

State to Whom

Present

Market Value

TOTAL

Schedule 4. Real Estate. The legal and equitable title to all the real estate listed in this schedule is solely

in the name of the signer, except if noted below:

Location or Street No.

& Description

Mortgage

or Liens

Due Dates &

Payment Amount

Unpaid Taxes

Cost

Present

Market

Value

Year

Amt.

TOTAL

CORP-M01 [09/23] Texas Department of Banking Page 23

**PROPERIETARY INTERESTS

(Schedule 5)

Provide the following information regarding all business enterprises in which you hold a beneficial interest. The term

"business enterprise" includes any corporation, association, partnership, business trust, sole proprietorship or other

business which shares are not listed on a securities exchange or otherwise regularly traded. Under the heading "Form

of Business", state the legal form of the business. Under "Nature of Business and Percentage of Ownership", explain

what the business enterprise does and percentage of your ownership interest. Submit year-end financial statements,

including profit and loss and cash flow statements, for the last year for each business interest in which you have an

interest equal to 25% or more of your net worth.

Name and Address of Business

Legal Form of

Business

Nature of

Business and % of

Ownership

Date Acquired

Current

Value

TOTAL

Schedule 6. Notes or Accounts Payable.

Name of Lender

Lender's Address

Due Dates

and Payments

Security or

Collateral

Balance

Owed

TOTAL

CORP-M01 [09/23] Texas Department of Banking Page 24

CASH FLOW STATEMENT

Provide the following information regarding sources and uses of cash during the last two years,

the current year, and a projected year.

Sources of Cash

20___

Current*

Projected

Salaries, Wages,

Commissions, Bonuses,

or Other Income from

Employment (Net of

Deduction)

Dividends

Interest

Royalties

Distributions

Cash Received from

Individual Business,

Partnership, or Joint

Ventures

Real Estate

Other**

Total Cash

Received

Uses of Cash

20___

Current*

Projected

Personal Expenses

(Management, Rent and

Household, Etc.)

Bank Loan – Principal

and Interest

Others Loans – Principal

and Interest

Insurance Payments

Income Taxes Not

Covered by

Withholding

Other**

Total Cash

Outlays

Cash Flow

Surplus

(Deficit)

If current year is reported for less than a full fiscal or annual period, please provide the dates for the period reported.

**Itemize any items amounting to 10% or more of total income on separate page.

CORP-M01 [09/23] Texas Department of Banking Page 25

APPENDIX B –

NOTICE TO ALL CORPORATIONS

APPLYING FOR MONEY

SERVICE BUSINESS LICENSES

PLEASE READ CAREFULLY

An applicant for a money service business license under Chapter 152, Texas Finance Code,

must demonstrate to the satisfaction of the Texas Banking Commissioner that the

corporation does not owe any delinquent franchise or other taxes to this state.

A Franchise Tax Account Status must be submitted with all new applications submitted by

corporations, limited liability companies, S corporations, professional corporations, and

Edge Act Corporations. The Franchise Tax Account Status states whether a taxable

entity’s right to transact business in Texas is intact at the time the query is made.

If an Applicant cannot provide a Franchise Tax Account Status, then its application must

include evidence and a statement of legal counsel satisfactory to the Department that the

Applicant does not owe any delinquent franchise or other taxes to this state.

You may contact the Texas Office of the Comptroller of Public Accounts at the numbers

listed below to request information for obtaining a Franchise Tax Account Status.

Franchise Tax Help

Toll Free: 1-800-252-1386

Austin Telephone: 512-463-4600

http://www.window.state.tx.us

CORP-M01 [09/23] Texas Department of Banking Page 26

APPENDIX C – SECURITY FORMS

CORP-M01 [09/23] Texas Department of Banking Page 27

MONEY SERVICES BOND

Policy Number _______________________

KNOW ALL MEN BY THESE PRESENTS, that ________________________________

(Name and Business Address of Applicant)

__________________________________________________________________________

of the City of ____________________ County of ____________________ and State of

____________________ as principal (the “principal” or “license holder”) and

________________________________ of the City of ____________________ County of

____________________ and State and zip code of ____________________ as surety, are held

and firmly bound unto the Texas Banking Commissioner (the “Commissioner”) and any customer

of the license holder for the use and benefit of the Commissioner and the Texas Department of

Banking (the “Department”) and any such customer of the license holder for any liability incurred

with respect to any currency exchange or money transmission business conducted by the license

holder under, subject to, or by virtue of the provisions of the Texas Finance Code, Chapter 152

(the “Code”), including without limitation any delinquent fee, assessment, cost, penalty, or other

amount imposed on and owed by the license holder to the Commissioner or the Department, in the

penal sum of _________________________________ Dollars, ($____________), for the

payment of which, well and truly to be made, we bind ourselves, our heirs, executors,

administrators, successors and assigns jointly and severally by these presents.

WHEREAS, the aforesaid principal has applied for a license under the provisions of the aforesaid

Code, and,

WHEREAS, the aforesaid Code provides, and includes as a precedent to the issuance of a license,

that the principal shall furnish a bond in accordance with and that satisfies the requirements of

§152.353 of the Code.

NOW THEREFORE, if the license holder will faithfully conform to and abide by the provisions

of this Code and will honestly and faithfully apply all funds received and perform all obligations

and undertakings in connection with any currency exchange or money transmission business under

the Code and will pay to the Commissioner and the Department and to any customer or recipient

designated by a customer all money that becomes due and owing to the Commissioner and the

Department or to such person under the provisions of the Code because of any such business by

the license holder under and by virtue of the provisions of the Code, then this obligation will be

void; otherwise will remain in full force and effect.

PROVIDED, HOWEVER, in no event shall all aggregate liability of the surety under this bond

for any and all claims to one or more claimants exceed the penal sum of this bond.

PROVIDED FURTHER, that the bond is conditioned that the principal will not violate the Code

or a rule adopted pursuant to the Code, as long as the principal holds a license issued by the

Department for activities conducted subject to the Code.

CORP-M01 [09/23] Texas Department of Banking Page 28

The bond shall remain in effect for the entire term of the license in connection with which it is

being issued, unless sooner revoked by thirty (30) or more days written notice to the

Commissioner.

If the surety herein shall so elect, this bond may be conditionally cancelled at any time by the

surety herein by filing with the Commissioner a thirty (30) days written notice of such conditional

cancellation, but said surety so filing said notice shall not be discharged from any liability accrued

under this bond or which shall accrue herein before the expiration of said thirty (30) day period.

The bond shall automatically renew for any succeeding renewals of the license without need of

any action or notice by any party.

IN WITNESS WHEREOF, we have duly executed the foregoing obligation this ______ day of

____________, 20___, to be effective on the ______ day of ____________, 20___.

Principal ______________________________

By __________________________________

(Print or Type Name)

Signature _____________________________

Title _________________________________

Surety ___________________________

By __________________________________

(Print or Type Name)

Signature _____________________________

Title _________________________________

CORP-M01 [09/23] Texas Department of Banking Page 29

DEPOSIT IN LIEU OF SURETY BOND

UNDER THE TEXAS FINANCE CODE CHAPTER 152

THIS CONTRACT AND AGREEMENT is entered into in triplicate on

_______________, 20____, between

_________________________________________________ (the "License Holder"), a(n)

__________________________ organized under the laws of the State of ____________ and

doing business in the State of Texas, and the Commissioner of the Texas Department of Banking

(the "Commissioner");

LEGAL AUTHORITY FOR DEPOSIT INSTEAD OF BOND

The License Holder is subject to the Texas Finance Code, Chapter 152 (the "Code"),

entitled “Money Services Modernization Act” regulating the business of currency exchange and

money transmission. Instead of furnishing all or part of the surety bond required by the Code,

the License Holder is permitted to deposit with the Commissioner an aggregate amount (the

"Security"), including cash, certificates of deposit and interest-bearing securities that equals the

total amount of the required bond or the remaining part of the bond. The License Holder may

deposit the Security with any financial institution possessing trust powers that is authorized to

conduct a trust business in the State of Texas acceptable to the Commissioner.

THE COMMISSIONER'S FINDING

The Commissioner finds that ____________________________________________ (the

"Custodian"), a(n) _____________________, located in _______________________, is

authorized to conduct trust business in the State of Texas, and is an acceptable Custodian for the

License Holder's deposit.

LICENSE HOLDER'S DEPOSIT

The License Holder deposits with Custodian the following Security and all renewals,

substitutions and replacements thereof:

It is agreed between the parties:

1. Subject to the provisions of the Agreement, the Security is deposited for the

benefit of the State of Texas and any creditor of the License Holder for any

liability incurred by the License Holder under and by virtue of the Code.

CORP-M01 [09/23] Texas Department of Banking Page 30

2. The Security deposited may be exchanged from time to time for other Security of

an equal par value that qualifies under the provisions of the law relating to this

deposit, such substituted Security to be with joint written approval of the

Commissioner, License Holder, and Custodian.

3. All interest or dividends on all Security deposited will be payable to or in

accordance with the instructions of the License Holder, unless the Commissioner

gives contrary notice in writing to the Custodian. The Commissioner's notice will

be effective two business days after the Custodian actually receives the notice.

4. The original principal amount of the Security deposited under the terms of this

Agreement (plus interest accruing after the effective date of any notice given in

accordance with paragraph 3 above) will be controlled exclusively by the

Commissioner, who has the right from time to time to withdraw it. However, any

withdrawal request from the Commissioner must be either:

(A) in writing and supported by a certified copy of an order of a court

of competent jurisdiction; or

(B) by an original or certified copy of a written order of the

Commissioner containing the Commissioner's signature.

Withdrawals by the Commissioner must satisfy any liability the Custodian has to

the Commissioner and will relieve the Custodian of all liability to License Holder

for the amounts withdrawn.

5. If the License Holder will:

(A) faithfully conform to and abide by the provisions of the Code;

(B) honestly and faithfully apply all funds received and perform all

obligations and undertakings for exchange issued and sold under the Code; and

owing to the State or to such person under and by virtue of the provisions of the

Code;

then the Commissioner will have no further right in or claim to the Security

covered by his Agreement, and must, by written order containing the signature of

the Commissioner, notify the Custodian of the termination of the Commissioner’s

rights in the Security. Unless the Custodian receives an original or a certified

copy of a written order from the Commissioner containing the signature of the

Commissioner or an order from a court of competent jurisdiction terminating the

Commissioner’s rights in the Security, Custodian may assume that this

CORP-M01 [09/23] Texas Department of Banking Page 31

Agreement remains in effect and that the rights of the Commissioner in the

Security remain in existence.

6. The Custodian may rely on any and all certified notices or certified orders of the

Commissioner submitted from the Commissioner to the Custodian under this

Agreement, purporting to bear the signature of the Commissioner, without further

inquiry into the authenticity of the signature or the authority or entitlement of the

Commissioner to issue such certified notices or orders.

7. All notices or orders to Custodian must be delivered by certified mail, return

receipt requested or by overnight or local delivery courier. All notices or orders

provided for under this Agreement will be deemed to be received when actually

received by the addressee. All parties must promptly notify all other parties of an

address change. Notices and orders to the Custodian must be addressed as

follows:

____________________________

(Custodian's Name and Address)

8. Nothing in this Agreement requires Custodian to violate any applicable laws, any

court order or the instructions of any bankruptcy trustee.

9. The Security is subject to Custodian’s terms and conditions of deposit accounts

now in existence and as they may be modified in the future, except to the extent

that the terms and conditions are specifically inconsistent with this Agreement.

10. Custodian is not liable for any indirect damages, lost profits, special, punitive or

consequential damages that arise out of or in connection with the obligations

contemplated by this Agreement. The provisions of this paragraph will survive

termination of this Agreement.

11. This Agreement is executed in triplicate originals, one to be kept by each of the parties

hereto, and one to be kept by the Custodian.

SIGNED AND DELIVERED in triplicate this _______ day of ______________, 20____.

__________________________________________

(License Holder)

CORP-M01 [09/23] Texas Department of Banking Page 32

By: __________________________________________

(Signature)

__________________________________________

(Printed Name)

__________________________________________

(Title)

__________________________________________

Banking Commissioner of Texas

______________________________________________________________________________

______, Custodian, hereby acknowledges receipt of the Security described in the foregoing

agreement, and covenants and agrees that the same will be held by it for the purposes and subject

to the terms and conditions of this agreement, but reserves the right to resign as Custodian by

giving 30 days written notice to the signers of the Agreement at the addresses specified below.

_____________________________ Banking Commissioner of Texas

_____________________________ 2601 North Lamar Blvd.

_____________________________ Austin, Texas 78705

_____________________________

(License Holder's Name and Address)

Custodian will become bound by the terms of this Agreement only after it receives an original

counterpart fully executed by all parties.

__________________________________________

(Custodian's Name)

By: _________________________________________

(Signature)

__________________________________________

(Printed Name)

__________________________________________

(Title)

DATED: __________________

CORP-M01 [09/23] Texas Department of Banking Page 33

APPENDIX D - ACH FORM

AUTHORIZATION FOR DIRECT PAYMENT

OF REGULATORY ASSESSMENTS (ACH DEBIT)

I hereby authorize the Texas Department of Banking (the “DOB”) and/or the Texas Comptroller of Public

Accounts, on behalf of the DOB, to initiate debit entries to the deposit account (the “account”) indicated

below at the depository financial institution (the “Depository”) indicated below, and to debit the same to

the account. I understand that debit entries will be initiated from the account to pay annual license and

assessment fees owed the DOB pursuant to §33.27 of the Texas Administrative Code and that I will be

given at least 15 days notice prior to the debit entry. I acknowledge that the entries must comply with the

provisions of U.S. law.

This authorization will remain in effect unless terminated because of a corporate reorganization. The

account information will remain effective unless modified because of a change in the account to which

debits are authorized. I understand that written notice of a termination or modification must be provided

to the DOB at least 30 days in advance of a scheduled debit.

Name of License Holder ____________________________________________________________

License Number ______________ Date _______________________________________________

Signature _____________________________ Title _______________________________________

Printed Name _____________________________________________________________________

THE FOLLOWING ACCOUNT INFORMATION MUST BE COMPLETED BY YOUR

FINANCIAL INSTITUTION:

Bank Name _____________________________________________________________________

Branch ___________________________________________________________________________

City _____________________________________________ State ______ Zip _________________

Bank Contact Name __________________________________________________________

Bank Contact Phone Number _________________________________________________________

ACH/Routing Number (9 digit number) _________________________________________________

Account Number ___________________________________________________________________

Type of Account ____ Checking ____ Savings