Form LFS400I (Revised November 2022) Page 1 of 4
STATE OF WISCONSIN
Department of Financial Institutions
Division of Banking
COLLECTION AGENCY LICENSE APPLICATION INSTRUCTIONS
Purpose: A completed Collection Agency License Application should be submitted to the Department of Financial
Institutions – Division of Banking (“division”) for consideration of licensure. Upon the filing of such application the
division shall investigate the relevant facts, and if the division finds that the character, general fitness and financial
responsibility of the applicant, including key officers, members, partners or owners, warrant the belief that the business
will be operated in compliance with Section 218.04, Wis. Stats., the division shall issue a license.
Notice: This form is required under Section 218.04, Wisconsin Statutes. Refusal to provide this information may result in
the denial of a license. Personally identifiable information on this form may be matched against tax information,
outstanding child and family support data and law enforcement agencies. Failure to complete this application completely
and accurately may result in denial or revocation of license, and any other penalties as provided by law.
Each section in the following application instructions identifies the corresponding application page number that it is
referring to.
APPLICANT INFORMATION (Pages 1-11)
Print or type the information requested in the spaces provided on pages 1 through 11 of the Collection Agency License
Application.
ATTACHMENTS (Page 12)
The following items may need to be submitted with your completed Collection Agency License Application. Additional
information regarding each item is included on pages 2, 3 and 4 of this instruction packet. Please read the instructions
to determine which items you will be required to submit.
A) Surety Bond
B) Financial Statements
C) Solicitor/Collector Application(s)
D) List of Solicitor/Collectors
E) Fees
F) Certificate of Good Standing if the applicant was incorporated/organized in a state other than Wisconsin
G) Criminal History Report(s)
H) Officer/Director/Owner Resume(s)
I) Contracts between Applicant and Independent Contractors
J) Business Plan
Form LFS400I (Revised November 2022) Page 2 of 4
A) Surety Bond
The applicant must provide a surety bond in the amount of $25,000 if all of its records are maintained within
Wisconsin, or $35,000 if any records are maintained outside of Wisconsin. The bond that is submitted to the
division:
must be completed on form LFS430 (Revised November 2022). Any bond that is not completed on this
form will be rejected. The bond form may be downloaded from the Department of Financial Institutions’
website, dfi.wi.gov, by selecting Financial Services and then Licensed Financial Services Applications
and Forms.
must NOT reference a street address.
must identify the exact name of the applicant.
must identify all trade names or DBA (doing business as) names that the applicant uses. If using more
than one DBA, please call our office for further instructions.
must identify only the fictitious name of the applicant if the Corporations Section of the Wisconsin
Department of Financial Institutions required the applicant to obtain a fictitious name.
must be the original surety bond. The original power-of-attorney form must also be submitted with the
bond.
must be signed by an officer/owner/member/partner whose signature is witnessed or sealed.
B) Financial Statements
An internally prepared balance sheet and income statement must be submitted for the applicant. Audited financial
statements should also be submitted if the applicant is audited by a certified public accountant on an annual basis.
The financial statements that are submitted to the division:
must be prepared according to Generally Accepted Accounting Principles using accrual basis accounting.
must be for the legal entity that is applying for the license (the parent’s financial statements are not
acceptable).
must show a minimum net worth of $15,000 and a minimum working capital (current assets – current
liabilities) of $7,500.
must be dated no more than 90 days prior to the date of this application.
The following information must be attached to the financial statements:
an itemization of the “Other Assets” category (if the balance sheet includes an “Other Assets” category)
documentation that verifies the cash balance listed on the balance sheet (this only needs to be submitted if
cash accounts for more than 20% of the total assets)
an explanation of how the applicant will maintain a net worth of at least $15,000 and working capital of at
least $7,500 at all times (this only needs to be submitted if the applicant’s equity or working capital are at
or near the minimum amounts required by the division)
an aging report for any accounts receivable identified on the balance sheet.
When evaluating a financial statement, the division typically discounts intangible assets; receivables from
officers, stockholders, and other related parties; employee advances; receivables over 90 days past due; and any
other assets of questionable value.
If the applicant is a sole proprietorship, provide a personal financial statement dated no more than 90 days prior to
the date of this application.
If the applicant is a partnership, each partner must submit a financial statement dated no more than 90 days prior
to the date of this application.
Form LFS400I (Revised November 2022) Page 3 of 4
C) Solicitor Collector Application(s)
Any solicitor or collector who will be working outside of the office must complete a solicitor/collector
application. Each completed application requires a $15 license fee. The solicitor/collector application form may
be downloaded from the Department of Financial Institutions’ website, dfi.wi.gov, by selecting Financial Services
and then Licensed Financial Services Applications and Forms.
*** If the solicitor/collector applicant is a veteran who is choosing to use the Veterans Fee Waiver Program for
his/her application; provide the authorization number obtained from the Wisconsin Department of Veterans
Affairs in the upper right hand corner of the application and do not include the filing fee.***
D) List of Solicitor/Collectors (if applicable)
Provide a list of all solicitors/collectors who will not be working outside of the office but will be using an alias
when contacting Wisconsin residents. The list should identify each solicitor’s/collector’s alias.
Note: Each person may use only one alias and each alias must include a first and a last name.
E) Fees
The fee is $1,200 plus an additional fee for each solicitor/collector. Make checks payable to the Department of
Financial Institutions.
The $1,200 fee consists of a $200 license fee and a $1,000 nonrefundable investigation fee.
A $15 annual license fee is required for each solicitor/collector who will be working outside of the office.
F) Certificate of Good Standing (if applicable)
If the applicant is organized or incorporated in a state other than Wisconsin, provide the division with a certificate
of status/certificate of good standing from the state where the applicant is organized or incorporated. The
status/certificate should be dated within the previous 90 days and reflect the correct name and the date of
organization or incorporation.
G) Criminal History Report
A criminal history report must be submitted for each individual who owns 10% or more of the applicant and for
each key officer, key member, or partner of the applicant. Key officers include, but are not limited to, the chief
executive officer, chief operating officer, chief financial officer, president, executive or senior vice president (or
the highest-level vice president if there is no executive or senior vice president), secretary, and treasurer. The
criminal history report must be dated within the previous 90 days and must be obtained from the state
police/Department of Justice located in the owner’s/officer’s/member’s/partner’s state of residence. Reports
obtained from third-party background check providers will not be accepted.
H) Officer/Director/Owner Resume(s)
Submit a resume for each individual who owns 10% or more of the applicant and for each key officer, director,
key member, or partner of the applicant. The resume should include a summary of educational and employment
experiences, the applicable dates of experience, positions held, name of company, and a description of duties.
I) Contracts between Applicant and Independent Contractors (if applicable)
Attach a copy of each contract between the applicant and all independent contractors hired by the applicant.
Examples of independent contractors include credit card processors, debit card processors, e-check payment
processors and letter vendors.
Form LFS400I (Revised November 2022) Page 4 of 4
J) Business Plan
Submit a business plan if the applicant is not yet in operation, or a detailed description of the mode of operations
if the applicant is currently operating. A business plan should include a description of the applicant’s proposed
products and services, its management team, and its records.
CHECKLIST (Pages 12 – 13)
The checklist sets forth common problems the division identifies on collection agency license applications. Please answer
each question on the checklist.
AFFIDAVIT (Page 13)
A duly authorized representative for the applicant should complete and sign the affidavit. The representative’s signature
must be notarized.
RETURN APPLICATION MATERIALS TO:
Department of Financial Institutions
Division of Banking
Mailing Address: Street Address:
PO Box 7876 4822 Madison Yards Way
Madison, Wisconsin 53707-7876 North Tower
Madison, Wisconsin 53705
HOW TO OBTAIN HELP AND ADDITIONAL FORMS:
INTERNET - Access the Department of Financial Institutions’ website, dfi.wi.gov, to:
download applications, instructions, and forms.
see answers to frequently asked questions.
see a list of collection agencies licensed under Section 218.04, Wisconsin Statutes.
TELEPHONE
Licensed Financial Services Section (608) 572-2672
Division of Banking (608) 261-7578
FAX
Division of Banking (608) 267-6889
This document can be made available in alternate formats upon request to qualifying individuals with disabilities.
Form LFS400 (Revised November 2022) COLLECTION AGENCY APP Page 1 of 13
Print or type the information requested in the spaces provided.
APPLICANT INFORMATION
1.
Name of applicant: The “applicant” is the corporation, limited liability company, limited partnership,
partnership or sole proprietorship that is applying for the license. If the applicant uses a trade name or DBA
(doing business as) name
, include that as well.
2.
Address and phone number of applicant’s headquarters office
Street:
Telephone Number:
City:
State: Zip: FAX Number:
3.
Mailing address of applicant’s headquarters office (if different than above)
Street:
PO Box:
City:
State: Zip:
Section 218.04(4)(a), Wis. Stats., requires a collection agency to maintain an active office in Wisconsin. Rule DFI-Bkg
74.01(2) defines an active office. A copy of this rule is attached to this application packet or may be accessed from our
website at dfi.wi.gov.
4. Provide the following information for the Wisconsin office.
Mark this box with an “X” if the Wisconsin office will be at the same location as the
headquarters office; if different, indicate below.
Section 218.04,
Wis. Stats.
STATE OF WISCONSIN
Department of Financial Institutions
COLLECTION AGENCY LICENSE
APPLICATION
Division of Banking
Mailing Address:
Courier Address:
PO Box 7876
Madison, WI
4822 Madison Yards Way
North Tower
53707
-
7876
Madison, WI
53705
Telephone: (608) 261
-
7578
dfi.wi.gov
Fax: (608) 267-6889
WISCONSIN OFFICE
Street Address:
City: State:
WI
Zip:
Telephone:
Fax:
Reset Form
COLLECTION AGENCY APP Page 2 of 13
5. Will the agency’s Wisconsin office or reception area be shared with anyone? Yes No
If yes, indicate who will share the office quarters and describe the nature of business to be conducted.
Note: Section 218.04(4)(b), Wis. Stats., indicates that no licensee shall conduct business in any office,
room or place of business in which any other business is solicited or engaged in, except as may be
authorized in writing by the division. A copy of this statute is attached to this application packet or may be
accessed from our website at www.wdfi.org.
GENERAL INFORMATION
6. Identify the location where records relating to the collection agency will be maintained for examination
purposes:
Street: City:
State: Zip: Telephone Number: FAX Number:
7. Identify the type(s) of collection services performed by the applicant:
Commercial Consumer Letter Writing
8. Provide the applicant’s website address, if any:
9. Provide the name and address of each financial institution where the applicant maintains a collection agency
trust account; also identify the account number of each trust account. Attach additional pages as necessary.
Financial Institution: Account Number:
Street: City: State: Zip:
Financial Institution: Account Number:
Street: City: State: Zip:
Financial Institution: Account Number:
Street: City: State: Zip:
10. Will the applicant maintain a Wisconsin trust account if they are issued a Wisconsin collection agency license?
Yes No
Form LFS400 (Revised November 2022)
COLLECTION AGENCY APP Page 3 of 13
11. Name, title, address, telephone number and e-mail address of person to whom questions regarding this
application should be addressed:
First Name: Last Name: Title:
Street: City:
State: Zip: Telephone Number: E-mail:
12. List states in which the applicant, and/or entities related to the applicant, currently hold a license to conduct
business as a collection agency. If no collection agency licenses are held in other states, complete this area to
disclose “None.” Attach additional pages as necessary.
State: License Number: Entity name used to conduct business in the noted state:
Name of State Agency:
State: License Number: Entity name used to conduct business in the noted state:
Name of State Agency:
13. List states, other than Wisconsin, in which the applicant, and/or entities related to the applicant, currently have
a pending collection agency license application. If there are no pending collection agency license applications,
complete this area to disclose “None.” Attach additional pages as necessary.
State: Name that will be used by the collection agency to conduct business in the noted state:
Name of State Agency:
State: Name that will be used by the collection agency to conduct business in the noted state::
Name of State Agency:
14. Indicate the type of organization with an “X.”
Corporation Partnership
Limited Liability Company Sole Proprietorship
Limited Partnership Other (Please Specify)
15. Provide the date and state of Incorporation/Organization.
Date: State:
Form LFS400 (Revised November 2022)
COLLECTION AGENCY APP Page 4 of 13
16. If the applicant is a corporation, a limited liability company, or
a limited partnership, provide the applicant’s Federal Employer
Identification Number:
If the applicant is a sole proprietorship or a general partnership,
provide each owner’s Social Security Number:
Note: Pursuant to Section 218.04(3)(a)1, Wis. Stats., this Department is required to obtain this information
from all applicants. The information will be shared with other state agencies for the purpose of matching
against tax information and outstanding child and family support data.
17. Has the applicant or any key officer, director, member, partner or owner ever Yes No
been licensed (credentialed) under any other name(s) in this state or any other
state?
If yes, identify the current name of the applicant/individual and identify all other names that the applicant/
individual is/was licensed under. Attach additional pages if necessary.
18. Has any key officer, director, member, partner or owner ever been issued a
professional license by the State of Wisconsin? Examples include an
insurance license, a real estate license or a securities license. Yes No
If yes, identify the name of the individual, the type of license the individual was issued, the agency the license
was issued by and the license number. Attach additional pages if necessary.
First Name of Individual: Last Name of Individual:
Type of License: Agency: License Number:
First Name of Individual: Last Name of Individual:
Type of License: Agency: License Number:
19. Does the applicant use any independent contractors (i.e. credit card processor, Yes No
debit card processor, e-check payment processor, letter vendor, etc.)
If yes, identify each independent contractor, describe the services that the independent contactor provides and
attach a copy of the contract that the applicant has entered into with the independent contractor.
Form LFS400 (Revised November 2022)
COLLECTION AGENCY APP Page 5 of 13
20. Is the applicant presently a defendant in any lawsuits that may materially Yes No
affect the applicant’s financial position?
If yes, provide details including the name of the plaintiff(s), amount(s) sued for, basis for the litigation, and its
current status. Attach additional pages if necessary.
21. Name, title, address, telephone number and e-mail address of person to whom future questions regarding
licensing matters can be directed if the applicant is issued a Wisconsin collection agency license.
First Name: Last Name: Title:
Street: City:
State: Zip: Telephone Number: E-mail:
22. Name, title, address, telephone number and e-mail address of person to whom future questions regarding
complaints can be directed if the applicant is issued a Wisconsin collection agency license.
First Name: Last Name: Title:
Street: City:
State: Zip: Telephone Number: E-mail:
23. Name, title, address, telephone number and e-mail address of person to whom future questions regarding
examination issues can be directed if the applicant is issued a Wisconsin collection agency license.
First Name: Last Name: Title:
Street: City:
State: Zip: Telephone Number: E-mail:
Form LFS400 (Revised November 2022)
COLLECTION AGENCY APP Page 6 of 13
PERSONNEL INFORMATION
24. Complete the following chart with personnel information that is relevant to the applicant. Attach additional pages if
necessary. You can determine what personnel information you need to provide by reading the following:
Corporation: List all key officers and directors. Also list all stockholders who own 10% or more of the outstanding
shares. Key officers include, but are not limited to, the CEO, COO, CFO, president, executive or senior vice
president (or the highest level vice president if there is no executive or senior vice president), secretary and treasurer.
Limited Liability Company (LLC): List all key members. Also list all other members whose interest in the LLC is
10% or more.
Limited Partnership: List all general partners. Also list all limited partners whose interest in the limited partnership
is 10% or more.
Partnership: List all partners.
Sole Proprietorship: List proprietor.
First Name: Last Name: Birth Date:
Residence Street Address: City: State: Zip:
Mark this box with an “X” if this individual is the only key officer/member/owner of applicant.
Mark all boxes that apply with an “X”:
This individual is a key officer/director/member/partner of applicant and his/her title is __________________.
This individual is an owner of applicant and he/she owns _______ % of applicant.
First Name: Last Name: Birth Date:
Residence Street Address: City: State: Zip:
Mark all boxes that apply with an “X”:
This individual is a key officer/director/member/partner of applicant and his/her title is __________________.
This individual is an owner of applicant and he/she owns _______ % of applicant.
First Name: Last Name: Birth Date:
Residence Street Address: City: State: Zip:
Mark all boxes that apply with an “X”:
This individual is a key officer/director/member/partner of applicant and his/her title is __________________.
This individual is an owner of applicant and he/she owns _______ % of applicant.
First Name: Last Name: Birth Date:
Residence Street Address: City: State: Zip:
Mark all boxes that apply with an “X”:
This individual is a key officer/director/member/partner of applicant and his/her title is __________________.
This individual is an owner of applicant and he/she owns _______ % of applicant.
Form LFS400 (Revised November 2022)
COLLECTION AGENCY APP Page 7 of 13
First Name: Last Name: Birth Date:
Residence Street Address: City: State: Zip:
Mark all boxes that apply with an “X”:
This individual is a key officer/director/member/partner of applicant and his/her title is __________________.
This individual is an owner of applicant and he/she owns _______ % of applicant.
First Name: Last Name: Birth Date:
Residence Street Address: City: State: Zip:
Mark all boxes that apply with an “X”:
This individual is a key officer/director/member/partner of applicant and his/her title is __________________.
This individual is an owner of applicant and he/she owns _______ % of applicant.
25. Indicate which key officer positions are currently vacant. (This item only needs to be completed if the applicant is a
corporation or an LLC that has key officers).
Chief Executive Officer Chief Operating Officer Chief Financial Officer
President Executive/Senior Vice President Secretary
Treasurer There are no vacant positions
26. Identify all legal entities that directly own 10% or more of the applicant. If any of the owners are a trust, also identify
the grantor(s) of the trust. Attach additional pages if necessary.
Entity Name:
Address:
City: State: Zip: % Ownership:
Entity Name:
Address:
City: State: Zip: % Ownership:
27. Any legal entity that indirectly owns the applicant must be identified. Provide the following information for each
owner of any entity listed in item #26 that owns 25% or more of the entity listed in item #26. Continue up the chain of
ownership, listing all 25% or more owners at each level of ownership and providing the following information, until a
public reporting company or a natural person is reached. If any of the owners are a trust, also identify the grantor(s) of
the trust. Attach additional pages if necessary.
Entity Name or First, Middle and Last Name if an Individual: Title if Individual:
Address:
City: State: Zip: % Ownership:
Form LFS400 (Revised November 2022)
COLLECTION AGENCY APP Page 8 of 13
APPLICANT BACKGROUND INFORMATION QUESTIONNAIRE
28. This questionnaire must be completed by a key officer, member or partner of the applicant. These questions pertain
to the business identified in item 1 of the application; they do not pertain to the officers, members or partners
of the applicant.
Mark an “X” in the appropriate box. If you answer “Yes” to any question, give all details on a separate sheet.
If any event or action arises after completing these questions and before action is taken by the division on this
application that would cause the applicant to answer “Yes” to any question, the applicant must immediately provide
all details in writing to the division.
Do not complete this questionnaire if you are a sole proprietor or general partnership.
Yes No
a. Has the applicant ever been the subject of disciplinary action including, but not limited to,
civil forfeitures, cease and desist orders, injunctions, license suspensions, denials,
revocations, warnings, reprimands, enforcement actions, probation and limitations by any
regulatory agency in this state or any other state? Provide details about the disciplinary
action, including but not limited to date, regulatory agency and type of discipline.
b. Is disciplinary action pending against the applicant in this state or any other state? Provide
details, including but not limited to action, regulatory agency and state.
c. Has the applicant ever surrendered, resigned, cancelled or been denied a professional license
or other credential in this state or any other state? Provide details, including but not limited
to date, credential and state.
d. Has the applicant been the subject of derogatory credit (bankruptcy, judgment, tax lien,
collections, etc.) within the past 10 years? Provide details, including but not limited to date,
circumstances and court or agency.
e. Has the applicant been denied credit within the past 10 years? Provide details, including but
not limited to entity denying credit and date.
f. Has the applicant been the subject of any suit, claim, or other civil action in this state or any
other state within the last 10 years that was settled or included a ruling or decision not in the
applicant’s favor? Provide a description of the suit, claim, or other civil action, agency or
court, date filed, and outcome.
g. Is a suit, claim or other civil action pending in this state or any other state against the
applicant? Provide details, including but not limited to a description of the suit, claim, or
other civil action, agency or court, date filed, and current status.
h. Has a bonding company ever denied, paid out on, or revoked a bond for the applicant?
Provide a detailed description of the circumstances that led to the bond being denied, paid
out on, or revoked, and the date such action occurred.
Initials of individual signing this questionnaire: ____________
Form LFS400 (Revised November 2022)
COLLECTION AGENCY APP Page 9 of 13
Yes No
i. Has the applicant ever been named as a respondent/defendant in a financial services-
related consumer-initiated arbitration which is still pending; or resulted in an arbitration
award against the applicant; or was settled for any amount? Provide details, including but
not limited to a description of why the consumer initiated the arbitration, the date
arbitration commenced, and the current status or outcome.
I, , the undersigned, being a key officer, member or partner
(Print Name)
of hereby certify that each statement and
(Name of Applicant)
representation in the Applicant Background Information Questionnaire is true and correct to the best of my
knowledge.
(Signature) (Title) (Date)
Note: This Department may independently conduct checks into background, experience and related matters in
conjunction with the filing of this application and representations therein. Failure to complete this application
completely and accurately may result in denial or revocation of the license, and any other penalties as provided by
law.
Form LFS400 (Revised November 2022)
COLLECTION AGENCY APP Page 10 of 13
INDIVIDUAL BACKGROUND INFORMATION QUESTIONNAIRE
29. This questionnaire must be completed by each key officer, director, member, partner or owner of the applicant.
Key officers include, but are not limited to, the chief executive officer, chief operating officer, chief financial
officer, president, executive or senior vice president (or the highest level vice president if there is no executive or
senior vice president), secretary and treasurer.
Mark an “X” in the appropriate box. If you answer “Yes” to any question, give all details on a separate sheet.
Copies of this form may be made.
If any event or action arises after completing these questions and before action is taken by the division on this
application that would cause the individual to answer “Yes” to any question, the individual must immediately
provide all details in writing to the division.
Yes No
a. Have you ever been convicted of any misdemeanor or felony in this state or any other state?
Provide details about the misdemeanor or felony, including but not limited to conviction,
conviction date, penalty and court.
b. Are there any felony or misdemeanor charges pending against you in this state or any other
state? Provide details about the pending charges, including but not limited to charge, date
and court.
c. Are you on probation or on parole for a conviction? Provide details including the terms of
incarceration and, if applicable, list name, address and telephone number of probation or
parole officer.
d. Have you ever been the subject of disciplinary action including, but not limited to, civil
forfeitures, cease and desist orders, injunctions, license suspensions, denials, revocations,
warnings, reprimands, enforcement actions, probation and limitations by any regulatory
agency in this state or any other state? Provide details about the disciplinary action,
including but not limited to date, regulatory agency and type of discipline.
e. Is disciplinary action pending against you in this state or any other state? Provide details,
including but not limited to action, regulatory agency and state.
f. Have you ever surrendered, resigned, cancelled or been denied a professional license or
other credential in this or any other state? Provide details, including but not limited to date,
credential and state.
g. Has your employment involuntarily been suspended or terminated in this state or any other
state? Provide details about the suspension or termination, including but not limited to name
and location of employer, reason and date.
h. Have you been the subject of derogatory credit (bankruptcy, judgment, tax lien, collections,
etc.) within the past 10 years? Provide details, including but not limited to date,
circumstances and court or agency.
i. Have you been denied credit within the past 10 years? Provide details, including but not
limited to entity denying credit and date.
Initials of individual signing this questionnaire: ____________
Form LFS400 (Revised November 2022)
COLLECTION AGENCY APP Page 11 of 13
Yes No
j. Have you been the subject of any suit, claim, or other civil action in this state or any other
state within the last 10 years that was settled or included a ruling or decision not in your
favor? Provide a description of the suit, claim, or other civil action, agency or court, date
filed, and outcome.
k. Is a suit, claim or other civil action pending against you in this state or any other state?
Provide details, including but not limited to a description of the suit, claim, or other civil
action, agency or court, date filed, and current status.
l. Have you been the key officer, director, member, partner or owner of any company that
failed in business or filed bankruptcy while you were a key officer, director, member,
partner or owner? Provide details, including company name(s), your position with the
company, dates, and circumstances.
m. Have you been the key officer, director, member, partner or owner of any company that
was the subject of disciplinary action including, but not limited to, civil forfeitures, cease
and desist orders, injunctions, license suspensions, denials, revocations, warnings,
reprimands, enforcement actions, probation and limitations by any regulatory agency in
this state or any other state while you were a key officer, director, member, partner or
owner? Provide details about the disciplinary action, including but not limited to
company name, date, regulatory agency and type of discipline.
I, , the undersigned, being a key officer, director, member or
(Print Name)
partner of hereby certify that each statement and
(Name of Applicant)
representation in the Individual Background Information Questionnaire is true and correct to the best of my
knowledge.
(Signature) (Title) (Date)
Note: This Department may independently conduct checks into background, experience and related matters in
conjunction with the filing of this application and representations therein. Failure to complete this application
completely and accurately may result in denial or revocation of the license, and any other penalties as provided by
law.
Form LFS400 (Revised November 2022)
Form LFS400 (Revised November 2022) COLLECTION AGENCY APP Page 12 of 13
ATTACHMENTS
30. Check the box next to the items that you are attaching to your application. Refer to the instructions to determine
which items you are required to attach.
A) Surety Bond (refer to page 2 of the instructions)
B) Financial Statements (refer to page 2 of the instructions)
C) Solicitor/Collector Application(s) (refer to page 3 of the instructions)
D) List of Solicitor/Collectors (refer to page 3 of the instructions)
E) Fees (refer to page 3 of the instructions)
F) Certificate of Good Standing (refer to page 3 of the instructions)
G) Criminal History Report(s) (refer to page 3 of the instructions)
H) Officer/Director/Owner Resume(s) (refer to page 3 of the instructions)
I) Contracts between Applicant and Independent Contractors (refer to page 3 of the instructions)
J) Business Plan (refer to page 4 of the instructions)
CHECKLIST
31. The following checklist addresses common problems that the division identifies on collection agency license
applications. Please answer each question on the checklist to ensure that you are submitting a complete application.
Yes No N/A
The division does not allow a trade name (doing business as name) to include a corporate
identifier. Examples of corporate identifiers include “Company,” “Co.,” “Corp.,” and “Inc.”
If your company will be using a trade name in Wisconsin, have you verified that the trade
name does not include a corporate identifier?
Were all key officers/directors/members identified on pages 6 and 7 of the application?
If any of the key officer positions are vacant, were those vacant positions identified on page 7
of the application?
Is a Certificate of Good Standing attached to this application if the applicant was incorporated/
organized in a state other than Wisconsin? Refer to page 3 of the instructions.
If you are required to submit a Certificate of Good Standing, was it dated within the previous
90 days? Refer to page 3 of the instructions.
Was your surety bond prepared on form LFS430? (Bond forms that have been reproduced
(retyped) by an insurance company are not acceptable.) Refer to page 2 of the instructions.
If the applicant uses a trade name, have you verified that the trade name is included on the
surety bond? Refer to page 2 of the instructions.
COLLECTION AGENCY APP Page 13 of 13
Yes No N/A
If the Corporations Section of the Wisconsin Department of Financial Institutions required the
applicant to use a fictitious name, does the surety bond identify only the fictitious name?
Refer to page 2 of the instructions.
Has page 2 of the bond been signed by an officer/owner/member/partner whose signature has
been either witnessed or sealed? Refer to page 2 of the instructions.
Have you attached the original surety bond and the power-of-attorney form that accompanies
it to this application? (A photocopy of the bond is not acceptable.) Refer to page 2 of the
instructions.
Have the financial statements been prepared according to generally accepted accounting
principles on an accrual basis? Refer to page 2 of the instructions.
Are the financial statements for the entity that is identified in item #1 of the application? (We
will NOT accept a financial statement for the applicant’s parent company.)
Have you attached an accounts receivable aging report to your application?
AFFIDAVIT
32. I, ____________________________________, the undersigned, being the duly authorized representative of
(Print Name)
_____________________________________________________ hereby certify that each statement and
(Name of Applicant)
representation in this application and in attachments to this application is true and correct to the best of my
knowledge.
______________________________________________________________________________________
(Signature) (Title) (Date)
SUBSCRIBED AND SWORN TO BEFORE ME
THIS _________ DAY OF _________________, __________
__________________________________________________
(Notary Public)
My Commission Expires: _____________________________
This form is required under Section 218.04, Wisconsin Statutes. Refusal to provide this information may result in the denial of
a license. Personally identifiable information on this form may be matched against tax information, outstanding child and
family support data and law enforcement agencies. Failure to complete this application completely and accurately may result in
denial or revocation of license, and any other penalties as provided by law.
This document can be made available in alternate formats upon request to qualifying individuals with disabilities
Form LFS400 (Revised November 2022)
