*Required field
FIS 2321 (02/17) Department of Insurance and Financial Services
Authorized by 1975 PA 148, as amended. Required for supervisory purposes.

 

Debt Management Annual Report

for the Calendar Year Ended December 31, 2016

 

DUE DATE - March 27, 2017

 

WARNING: Failure to file an annual report will result in commencement of administrative action against the license. All questions refer only to services provided under the Debt Management Act (DMA) 1975 Public Act 148, as amended.

 

Any false statement, misrepresentation, or fraud in connection with this report may be cause for revocation, suspension, or other disciplinary action against the company's license.

 

 
 
 

 

NOTE: The information provided should pertain only to debt management services provided to Michigan residents. All spaces must be completed; indicate "0" if a response does not apply.

 

 
 
 
 
 
 
 
 
 
 
*5. b. If 'Yes', check each product that is offered.



 
 
 
 
 
 
 
 
 
 
*7. Indicate the payment method available for clients. Check all that apply.



*8. Indicate whether the following payment methods can be used by the licensee to pay creditors. Check all that apply.




CERTIFICATION

By including the identification number, the person submitting this report hereby certifies that he/she is authorized to submit this report and has read and knowingly made the statements and representations on this report and that each and every such statement and representation is true, accurate and complete to the best ability of his/her knowledge and belief. He/she understands that any false statement, misrepresentation, or fraud in connection with this report may be cause for revocation, suspension or other disciplinary action against the company's license.