FOR OFFICE USE ONLY

DATE APPLICATION REC’D:  ____________________________

AMOUNT FEE REC’D:  	          ____________________________

CASH [     ]     CHECK [     ]

CHECK NO:     ________________________________________

Cash NO: ____________________________________________
STATE OF MAINE
BUREAU OF CONSUMER CREDIT PROTECTION
NEW / USED AUTO DEALER CREDIT SALES NOTIFICATION
35 STATE HOUSE STATION
AUGUSTA, ME 04333-0035
TELEPHONE: (207) 624-8527 FAX: (207) 582-7699
In accordance with the provisions of the
Maine Consumer Credit Code, this
notification is hereby filed with the
Superintendent of the Bureau of Consumer
Credit Protection.

NOTE: Please complete all the following information. Failure to do so will delay the review of your application until the requested information is provided.
1.	Business Name: __________________________________________________________________
Mailing Address: _________________________________________________________________
City: _________________________________ State: _________________ Zip: _______________
Physical Address: ________________________________________________________________
City: _________________________________ State: _________________ Zip: _______________
Telephone: __________________________________ Fax: _______________________________
D/B/A: _________________________________________ FEIN/SS# _______________________
2.	Please attach a copy of your Bureau of Motor Vehicles Dealer License.
Is this dealership currently operating under this name?	[    ] Yes	[    ] No
If yes, please indicate start date: _______ / ________ / ___________
If not, what is your proposed start date? _______________________________
3. 	Business Structure:	[    ] Proprietorship 	[    ] Partnership	[    ] Corporation
4.	Owner’s Name(s): ________________________________________________________________
_______________________________________________________________________________
Telephone(s): ___________________________________________________________________
5.	General Manager’s Name: _______________________________ Telephone: _________________

6.	Sales Manager’s Name: _________________________________ Telephone: _________________

7.	Designated person for consumer complaints: ___________________________________________
Telephone: __________________________ E-mail: __________________________________

8.	Number of additional dealership locations that extend credit to Maine consumers: _____________
Locations (attach additional sheet if necessary):______________________________________

9.	Name of companies hired to conduct repossessions in Maine:______________________________
_______________________________________________________________________________
Number of Maine repossessions conducted during the last calendar year: __________________

10.	Financing source(s) (use separate sheet if necessary)
List all sales finance companies, banks or others to which consumer credit transactions were assigned during the past calendar year, and the dollar amounts assigned:
Name: ______________________ Address: ____________________________ $ _____________
Name: _______________________ Address: ___________________________ $ _____________
Name: _______________________ Address: ___________________________ $ _____________

11.	Check all activities undertaken by your dealership:
A. New Car Sales						[    ] Yes	[    ] No
B. Used Car Sales						[    ] Yes	[    ] No
C. Buy Here/Pay Here (In-House Financing)			[    ] Yes	[    ] No
D. Selling/Assigning Contracts to Finance Companies	[    ] Yes	[    ] No
E. Leasing							[    ] Yes	[    ] No
F. Other, please specify: ______________________________________________

12.	List original, unpaid balances of all Maine consumer credit transactions entered into during the past calendar year. Include all amounts assigned to the finance sources listed above, unless those companies have already paid the volume fee on the dealership’s behalf. If the financing sources have paid the volume fee, leave subsection 11 (B) blank.
A.	Internal Credit (In-house financing)
Closed-End Credit Sales			$ ______________________
B.	Leases (If applicable)				$ ______________________
C.	Assigned Credit
(If applicable)					$ ______________________
D.	Total Volume (A + B)				$ ______________________

13.	Fees Due:

A.	Volume Fee (See Schedule on next page)	$ ______________________
B.	Annual Notification Fee (Main Office)	$ 		20.00		
C.	Branch Fee ($10 Each Additional Location)	$ ______________________
D.	Total Fees Due (Sum of A, B. & C)		$_______________________

	I hereby certify that the statements in the foregoing report are true and correct to the best of my knowledge and belief.
Dated at: __________________ this _______________ day of ______________, __________

							__________________________________
							Signature
							__________________________________
							Name Typed or Printed Legibly
							__________________________________
							Title

If you have any questions about completing this form, call the Bureau at (207) 624-8527
RETURN CHECKS WITH PROPER FEES TO:
Bureau of Consumer Credit Protection, #35 State House Station, Augusta, ME 04333-0035
All checks must be payable to “Treasurer, State of Maine”
For overnight private carriers, send to 76 Northern Ave, Gardiner ME 04345

NOTICE REGARDING PUBLIC INFORMATION
This application is a public record for purposes of Maine’s Freedom of Access Law, 1 MRSA 401, et seq. Public records must be made available to any person upon request. Information that you supply as part of this application (except your Social Security Number) is public information. Other licensing records to which this information may later be transferred are also considered public records. Where permitted by law, your name, license number, mailing address, and other information listed on this application may be posted on the State’s website.
SCHEDULE OF FEES

USE TOTAL VOLUME FROM LINE 12 (D)

VOLUME AMOUNT		FEE				VOLUME AMOUNT		FEE

$           1 TO $100,000 - - - - - - - - - - - $ 25				$500,001 TO $600,000 - - - - - - - - - - - $150
$100,001 TO $200,000 - - - - - - - - - - - $ 50				$600,001 TO $700,000 - - - - - - - - - - - $175
$200,001 TO $300,000 - - - - - - - - - - - $ 75				$700,001 TO $800,000 - - - - - - - - - - - $200
$300,001 TO $400,000 - - - - - - - - - - - $100				$800,001 TO $900,000 - - - - - - - - - - - $225
$400,001 TO $500,000 - - - - - - - - - - - $125				$900,001 TO $1,000,000 - - - - - - - - - -$250*

*If your volume was in excess of $1,000,000 you can readily calculate the fee by extending the schedule.