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Annual Statement by a Licensed Credit Provider (Body Corporate) Please use a pen and write neatly using BLOCK LETTERS. Tick where appropriate ; This annual statement must also be accompanied by the prescribed fee and those additional items listed in the attached checklist. 1. Applicant Details Department of Consumer & Employment Protection Ground Floor “Forrest Centre” 219 St Georges Terrace PERTH WA 6000 Locked Bag 14 Cloisters Square WA 6850 Licensing Advice Line 8:30am to 5.00pm Monday to Friday Tel: 08 9282 0833 Fax: 08 9282 0559 Country Callers 1300 30 40 54 Web Site www.docep.wa.gov.au Licence Number Name of Body Corporate ACN ABN Business Name(s) Attach additional sheet if necessary Since the grant of the licence or since the last annual statement, whichever is the later, has the company changed its name or changed the business name(s) under which it operates its credit providing business? Yes / No Attach a page detailing any changes together with any certificate(s) of change of company name or certificate(s) of registration of any new business name(s) Principal Place of Business If no place of business in Western Australia insert the principal place of business in Australia Primary Postal Address If different than above Other Place(s) of Business Phone and Fax Numbers Ph F ( ) ( ) Email Address Registered Office Address If body corporate was not incorporated in Australia provide the address of the body corporate’s principal office in Australia Yes / No During the last year, did the body corporate carry on business as a credit provider in partnership with another person? If the answer is ‘Yes’ please provide the following details for each partner or proposed partner: Full name Address Attach additional sheet if necessary NOTE: It is an offence, with a maximum fine of $5,000, for the holder of a credit provider’s licence to carry on a business of providing credit in partnership with a person who is not the holder of a credit provider’s licence. 2. Responsible Persons In the space below (attach additional sheet if necessary), provide details of all Directors of the body corporate, all persons who are, or will be involved, in the day-to-day management of the credit providing aspect of the *body corporate, and all sons who have control, or substantial control of the body corporate**. per Full Name (and any previous names) Position or Role Residential Address Date of Birth Place of Birth Attach additional sheet if necessary *Include only the body corporate’s Chief Executive Officer in Australia and those employees of the corporation who take part in formulating policy in respect of credit providing in the corporation’s head office in Australia. If the body corporate’s head office is not in Western Australia, include also those persons at the body corporate’s principal place of business in Western Australia who are engaged in the anagement of the body corporate’s credit providing business. m **Include details of any person or body corporate in accordance with whose directions or instructions the Directors of the applicant are accustomed to act or who are in a position to directly or indirectly cause or require the Directors of the applicant to act in accordance with heir directions or instructions, whether now or in the future. t For each of the persons listed in respect of item 2 above attach: Annually: Statement of particulars (see Appendix 1). Triennially: a credit history report from an approved credit reference provider (not more than three months old) - this report can be obtained free of charge within two weeks (or for a fee if it is required within a shorter period) by contacting Veda Advantage on (02) 9464 6000 or Dun & Bradstreet on 132333 or www.mycreditfile.com.au; and original National Police Clearance (not more than three months old) - these can generally be obtained from Australia Post; (Please refer to the covering letter accompanying this form for advice as to if you are in a triennial year.) For each of the persons listed in respect of item 2 above who have commenced with the company since the grant of the licence or the last annual statement, whichever is the later and, if not already provided since becoming a Director, attach: two business references (see Appendix 2 pro forma); statement of experience, together with copies of any relevant qualifications, certificates or proof of successful course completions; a credit history report from an approved credit reference provider (not more than three months old) - this report can be obtained free of charge within two weeks (or for a fee if it is required within a shorter period) by contacting Baycorp on (02) 9464 6000 or www.mycreditfile.com.au; and original National Police Clearance (not more than three months old) - these can generally be obtained from Australia Post. 3. Shareholder Details In the space below, provide details of any person who since the grant of the licence or the last annual statement, whichever is the later, has come to hold a share in the body corporate of 25% or greater. Full Name (and any previous names) Share holding(%) Residential Address Date of Birth Place of Birth 4. Fitness of Body Corporate to Hold a Licence Since the grant of the licence or since the last annual statement, whichever is the later, has the body corporate or an associated entity: (a) Had an application refused for an authorisation (eg. licence, certificate, registration) under any Act relating to the regulation of any business, trade, profession, industry or occupation? Yes / No (b) Withdrew an application for such an authorisation? Yes / No (c) Had such an authorisation granted, which for any reason is no longer in force? Yes / No (d) Been subject to disciplinary action in relation to any such authorisation? Yes / No (e) Been the subject of any investigations or proceedings that are still current or pending and which may result in disciplinary action being taken in relation to any such authorisation? Yes / No (f) Been convicted or found guilty of any offences? Yes / No (g) Entered into a recognisance, which is still in force, in relation to any offence? Yes / No (h) Been subject to any charge in relation to any offence for which proceedings are still pending, including proceedings by way of appeal or review? Yes / No If you answered ‘Yes’ to any of the above questions attach to this application full and complete particulars in respect of each matter including, if you wish, any mitigating circumstances. 5. Confidential Statement of Assets and Liabilities Since the grant of the licence or since the last annual statement, whichever is the later, has the body corporate or an associated entity, in Australia or elsewhere: (a) Been placed under a receiver, or manager? Yes / No (b) Been wound up? Yes / No (c) Entered into a compromise, or scheme of arrangement, with its creditors? Yes / No If you answered ‘Yes’ to any of the above questions attach to this application full and complete particulars in respect of each matter including, if you wish, any mitigating circumstances. Please attach a credit history report (not more than 3 months month old) for the body corporate every third year after the granting of the licence. If you are not sure which year you are required to provide this document please contact a Licensing Officer on (08) 9282 0833. This report can be obtained free of charge within two weeks (or for a fee if it is required within a horter period) by contacting Baycorp on (02) 9464 6000 or www.mycreditfile.com.au s Yes / No The Directors of the body corporate have reason to believe that it will be able to meet any debts as and when they become due and payable. Yes / No The Licensee has, and is likely to continue to have, sufficient financial resources to carry on business pursuant to the authority conferred by a credit provider’s licence. *If you answered yes, please provide the following details: (a) Total assets of the Applicant/ Body Corporate $ (b) Total liabilities of the Applicant/ Body Corporate $ (c) Net worth of the Applicant/ Body Corporate $ *The information provided is a confidential statement that will only be used for assessing the financial resources of the licensee for the purpose of the Credit (Administration) Act 1984 Please attach a certified copy of that portion of the company’s Minutes detailing the solvency resolution passed by the company in respect of its last Annual Statement for the Australian Securities and Investments Commission (“ASIC”) and/or a copy of the company’s most recent Financial Report lodged with ASIC (If a solvency resolution was not passed and a Financial Report was not lodged with ASIC within the last 12 months please provide a written explanation). 6. Amount of Relevant Credit / Annual Fee (A)verage amount of relevant credit provided in Western Australia in each of the last 12 months $ (F)ee payable $ See Section 9 for more information regarding the above 7. Annual Statement Certification In order to assist the Commissioner for Consumer Protection with assessment of this annual statement I give authorisation to the Commissioner, or persons (s)he directs, to obtain on behalf of the body corporate copies of: (a) current or historical criminal records relating to any offence committed by the body corporate; (b) any Court transcript or records for proceedings to which the body corporate has been a party; (c) any decision in proceedings before any Board to which the body corporate has been a party; (d) any other document or file relating to another occupational licence that the body corporate has held or for which it has applied; and (e) any other document or file that may be necessary to assist the Commissioner with assessment of this application. I further agree, during the currency of this annual statement, to do all things necessary to assist the Commissioner in obtaining the above records upon request. Having been duly authorised by the licensee company to do so, I hereby certify on behalf of the licensee company that the particulars and answers given in respect of this annual statement are to the best of my knowledge and belief, complete, correct and true. Note: In relation to this application it is an offence, with a maximum fine of $5,000, for a person to make a statement that is false or misleading by reason of the inclusion of any false or misleading matter or the omission of any material matter. Signature Date Telephone Number Name Position (Director, Secretary, Manager, Solicitor, etc) 8. Annual Statement Checklist – Body Corporate Prior to submitting your annual statement complete this checklist, attaching any supporting documentation in the order set out below, numbering the various attachments and writing the page numbers in the column provided. Information to be supplied Annually Annual Statement – Body Corporate Prescribed fee (See Section 9). Cheques are to be made payable to the Commissioner for Consumer Protection A copy of the Certificate of Change of Name of the company (if applicable) Statement of Particulars (See Appendix 1) for each person listed in Section 2 Solvency resolution / financial statements (see Section 5) Information to be supplied regarding recently appointed Directors/ Responsible persons. Two business references (see Appendix 2 pro forma) for each person listed in Section 2 who has recently commenced with the company Statement of Experience for each person listed in Section 2 who has recently commenced with the company, together with copies of any relevant qualifications, certificates, or proof of successful course completions An original National Police Clearance (not more than three months old) for each person listed in Section 2 who has recently commenced with the company A credit history report from an approved credit reference provider (not more than three months old) for each person listed in Section 2 Information to be supplied Triennially (refer to covering letter for advice) An original National Police Clearance (not more than three months old) for each person listed in Section 2 A credit history report from an approved credit reference provider (not more than three months old) for each person listed in Section 2 A credit history report from an approved credit reference provider (not more than three months old) for the body corporate Your completed annual statement may be posted to: Or delivered in person to: The Commissioner for Consumer Protection Department of Consumer & Employment Protection Locked Bag 14 Ground Floor, Forrest Centre Cloisters Square 219 St Georges Terrace PERTH WA 6850 PERTH WA 6000 For more information contact a Licensing Officer on (08) 9282 0833 Please note: Where a change occurs to your license details, you are required to inform the Commissioner for Consumer Protection, by way of a written notice, within 14 days of the change. 9. Calculation of Annual Fee The Formula The Credit (Administration) Regulations 1985 provide that the annual fee payable by a licensed credit provider is calculated as follows: F = 12 x A 1000 where F means the fee payable A means the average amount of credit as determined by the Commissioner provided by the credit provider under transactions to which the Credit Act or the Code applied or applies in each of the 12 months of the period ending on the nniversary of the grant of the licence to the licensee. a Minimum and Maximum Fees The Regulations provide that the amount payable shall be not less than $440 and shall not exceed $23,000. A failure on the part of the licensee to lodge the annual statement and pay the annual fee, within 28 days after the anniversary date, will result in an additional late fee totalling 10% of the licence fee (with a minimum late fee of $50). Fees for Partners and Trustees Where a licensee carries on business as a partner, the fee payable shall be the fee payable calculated by reference to the amount of credit provided by the partnership and divided by the number of partners in the partnership at the time that the fee is payable and, where the licensee is a partner in more than one partnership, the sum of those amounts. Where a licensee carries on business on his own account and as a partner, the fee payable shall be the sum of the amounts payable on his own account and as a partner. Where a licensee is one of the trustees of a trust the fee payable shall be calculated as though the licensee were a partner and the other trustees were partners. 10. For Credit Card Payment – applicant to complete Card Type Visa Mastercard Bankcard Card Number Expiry Date CardHolder Please print Signature/Authorisation APPENDIX 1 STATEMENT OF PARTICULARS – TO BE COMPLETED BY EACH DIRECTOR 1. Statement of Particulars in Support of an Application for a Credit Providers Licence (Body Corporate) Name of Body Corporate Full Name of Individual Date of Birth Previous Name(s) Residential Address Phone and Fax Number 2. Have you or an associated entity in Australia or elsewhere: (a) Had an application refused for an authorisation (eg licence, certificate, registration) under any Act relating to the regulation of any business, trade, profession, industry or occupation? Yes / No (b) Withdrawn an application for such an authorisation? Yes / No (c) Had such an authorisation granted, which for any reason is no longer in force? Yes / No (d) Been subject to disciplinary action in relation to any such authorisation? Yes / No (e) Been the subject of any investigations or proceedings that are still current or pending and which may result in disciplinary action being taken in relation to any such authorisation? Yes / No (f) Been convicted or found guilty of, any offences? (Include all traffic offences that went to court but do not include spent convictions) Yes / No (g) Entered into a recognisance, which is still in force, in relation to any offence? Yes / No (h) Been subject to any charge in relation to any offence for which proceedings are still pending, including proceedings by way of appeal or review? Yes / No (i) Been an officer of a body corporate that has been placed under a receiver, or manager, or wound up, or which has entered into a compromise, or scheme of arrangement, with its creditors? Yes / No (j) Been a bankrupt? Yes / No If you answered ‘Yes’ to any of the above questions attach to this statement full and complete particulars in respect of each matter, including, if you wish any mitigating circumstances. 3. Authority to Release Personal Information In order to assist the Commissioner for Consumer Protection with assessment of this application I give authorisation to the Commissioner, or persons (s)he directs, to obtain on my behalf copies of: (a) current or historical criminal records relating to any offence committed; (b) any court transcript or records for proceedings to which I have been a party; (c) any decision in proceedings before any Board to which I have been a party; (d) any other document or file relating to another occupational licence that I have held or for which I have applied; and (e) any other document or file that may be necessary to assist the Commissioner with assessment of this application. I further agree, during the currency of this application, to do all things necessary to assist the Commissioner in obtaining the above records upon request. I provide this statement in relation to an application by a body corporate for a credit provider’s licence under the Credit (Administration) Act 1984 and certify that the particulars and answers given in respect of this statement are to the best of my knowledge and belief, complete, correct and true. Note: In relation to an application for a credit provider’s licence it is an offence, with a maximum fine of $5,000, for a person to make a statement that is false or misleading by reason of the inclusion of any false or misleading matter or the omission of any material matter. Full Name Signature Date APPENDIX 2 APPLICATION FOR A CREDIT PROVIDER’S LICENCE PRO FORMA BUSINESS REFERENCE (Body Corporate) References from relatives, subordinates or partners will not be accepted. At least one reference must be from a person external to your current place of employment. References from co-directors will not be accepted. Referees should provide as much detail as they are able to and attach an additional sheet if necessary. Where the Commissioner for Consumer Protection is unable to determine the applicant’s suitability for a credit provider’s licence under sections 12(2) and 12(4) of the Credit Administration Act 1984 (“the Act”) and associated regulations due to insufficient information being provided in support of the individual’s application, the reference will not be accepted. The questions below are intended to assist the Commissioner for Consumer Protection in determining whether an individual, director or person concerned with the management of a body corporate is of good character and repute and a fit and proper person to hold a licence pursuant to statutory requirements. Individual for whom reference is provided _____________________________________ Relevant Body Corporate ___________________________________________________ Referee’s Name (please print) .................................................................................................. Job title/Place of Employment ................................................................................................... Contact Number(s) .................................................................................................................... Questions 1. How long have you known the individual? ........................................................................ 2. Are you related to the individual in any way? .................................................................... .......................................................................................................................................... 3. What is the capacity and extent of your business relationship (and social relationship, if any) with the individual? .................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... 4. Do you believe the individual to be a person of good character and repute, a fit and proper person to hold a licence and likely to carry on business honestly and fairly? ....... Reason for this? ................................................................................................................ .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... 5. Do you consider the body corporate to be of good repute and likely to carry on the business honestly and fairly? ........................................................................................... Reason for this? ................................................................................................................ .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... 6. Do you believe that the applicant body corporate has sufficient material and financial resources to carry on business as a credit provider if the licence is granted?.................. Reason for this? ................................................................................................................ .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... 7. What experience and expertise does the individual have in relation to credit provision? .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... 8. What experience and expertise do the other officers of the body corporate have in relation to credit provision? ............................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... 9. Are you aware of any reason why the individual would not be eligible for, or should not be granted, a credit provider’s licence? (including but not limited to undischarged bankruptcy, licence disqualification, convictions). If yes, please provide details............... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... 10. Do you know of any person, other than an officer of the body corporate, who appears to have control or substantial control of the body corporate and who is not of good reputation and character and is not likely to exercise control honestly and fairly? ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... 11. Are you aware of any reason why the body corporate would not be deemed fit and proper to be eligible for a credit provider’s licence? (including but not limited to either the body corporate itself or one of its directors or managers having any convictions, licence disqualifications or undischarged bankruptcies). If yes, please provide details. ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... DECLARATION I sincerely declare that the particulars and answers given in respect to this reference are, to the best of my knowledge and belief, complete, correct and true. This declaration is true and I know that it is an offence to make a declaration knowing that it is false in a material particular. This declaration is made under the Oaths, Affidavits and Statutory Declarations Act 2005. Declared at . Dated this.....................................................................day of ....................................20 ......... Referee’s Name (Please Print) ................................................................................................. Referee’s Signature .................................................................................................................. In the presence of [refer to section 12 and schedule 2 of the Oaths, Affidavits and Statutory Declarations Act 2005 for list of Authorised Persons]: Witness’ Signature.................................................................................................................... Print Name of Witness ............................................................................................................. Qualification as such a witness (e.g. JP, Public Servant, etc) .................................................. Any person who knowingly makes a statement that is false in a material particular in a statutory declaration is guilty of a crime and is liable to imprisonment for 5 years.
