Surrender Form - Pennsylvania Department of Banking Forms/Consumer... Department of Banking and...

Surrender Form - Pennsylvania Department of Banking Forms/Consumer... Department of Banking and Securities
Surrender Form - Pennsylvania Department of Banking Forms/Consumer... Department of Banking and Securities
download Surrender Form - Pennsylvania Department of Banking Forms/Consumer... Department of Banking and Securities

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Transcript of Surrender Form - Pennsylvania Department of Banking Forms/Consumer... Department of Banking and...

  • Department of Banking and Securities – Non-Depository Licensing Office 17 N 2nd St, Ste 1300 | Harrisburg, PA 17101 | 717.787.3717 | F 717.787.8773 | www.dobs.pa.gov

    Surrender Form

    Name of Company:

    Office Type Surrendering License(s): Main Office: Branch Office(s): All:

    License Number(s) (if all offices are closing, only list Main Office Number, otherwise list all closing branch license numbers:

    Effective Date of Closure/Surrender:

    Reason for License Surrender:

    State: Zip:

    Custodian of Records:

    Name:

    Street Address:

    City:

    Telephone: Fax: Email Address:

  • Location of Records: Street Address: City: State: Zip: Please Attach the following information on the status of each loan to Pennsylvania consumers that are outstanding:  Name of Consumer  Consumer Address and telephone number  Current Application Status  Loan Number  Amount of Loan  Contact information for applicable lender with who each loan will be placed  Date loan will be resolved

    Contact Information: Name: Title: Firm Name (if applicable): Street Address: City: State: Zip: Telephone: Fax: Email Address: I understand by submitting this Surrender Request: I am agreeing to be bound by the following declaration: "I declare that all of my answers on this Surrender Request are complete, true and correct. I make this declaration subject to the penalties of 18 PA.C.S. § 4904 relating to unsworn falsification to authorities.” Name: Title: Signature: Date:

    Surrender Company: Surrender PPOB: Off Surrender Branch: Off Surrender All: Off Surrender Branch 2: Surrender Branch 3: Surrender Branch 4: Surrender Branch 5: Surrender Branch 6: Surrender Branch 7: Surrender Branch 8: Surrender Branch 9: Surrender Branch 10: Surrender Branch 11: Surrender Branch 12: Surrender Branch 13: Surrender Branch 14: Surrender Branch 15: Surrender Branch 16: Surrender Branch 17: Surrender Branch 18: Surrender Branch 19: Surrender Branch 1: Surrender Branch 20: Surrender Branch 21: Surrender Branch 22: Surrender Date: Surrender Reason: Surrender Custodian: Surrender Custodian St: Surrender Custodian City: Surrender Custodian state: Surrender Custodian Zip: Surrender Custodian phone: Surrender Custodian Fax: Surrender Custodian email: Surrender Records st: Surrender Records city: Surrender Records State: Surrender Records zip: Surrender Contact name: Surrender Contact Title: Surrender Contact Business Name: Surrender Contact St: Surrender Contact City: Surrender Contact State: Surrender Contact Zip: Surrender Contact Phone: Surrender Contact Fax: Surrender Contact Email: Surrender Authorization title: Surrender Authorization name: Surrender Authorization Date: