Collection Agency-Debt Collector Registration Form {I-1}

Tom Schedler Secretary of State COLLECTION AGENCY/DEBT COLLECTOR REGISTRATION FORM (Pursuant to R.S. 9:3534.1 B) Enclose $25 filing fee Make remittance payable to Secretary of State Do Not Send Cash Return to: Commercial Division P. O. Box 94125 Baton Rouge, LA 70804-9125 Phone (225) 925-4704 Web Site: www.sos.la.gov CHECK ONE: ( ) Original Filing ( ) Amendment ( ) Name Change The full legal name of the Collection Agency or Debt Collector is Previous name of the Collection Agency or Debt Collector is Jurisdiction of Organization if Collector is a company Address where legal process may be served Name of Employer if Collector is an individual Signature of Authorized Representative Date INSTRUCTIONS 1. File this form along with the $25 filing fee with the Secretary of State's office. 2. You will receive a copy marked "Received and Filed" by the Secretary of State. SS I-1 01/15 American LegalNet, Inc. www.FormsWorkFlow.com