APPLICATION FOR REGISTRATION AS A

RETAIL GROCERY STORE CHECK CASHER Branch

PART 1

The Pennsylvania Department of Banking and Securities (“the Department”) welcomes your request for this Retail Grocery Store Check Casher application. This portion of the application provides general information that will be of value to you when you complete the written portion of the application.

The Department issues Retail Grocery Store Check Casher registrations under the provisions of the Check Casher Licensing Act, which sets forth requirements both to become and to remain registered. The Department is responsible for registration provision of the Check Casher Licensing Act.

It is imperative that you become familiar with the Check Casher Licensing Act and the regulations issued thereto. You may wish to consult with an attorney. The legal citation for the Check Casher Licensing Act is 63 P.S. §§ 2301-2334 and is available on the Department’s website at www.dobs.pa.gov. Regulations are found within Title 10, Pennsylvania Code, Chapter 81, which is also available on the Department’s website.

Registration Required

Section 1101 of the Check Casher Licensing Act. A retail food store licensed as a public eating or drinking place, as defined by section 1 of the Public Eating and Drinking Place Law, that receives less than 1% of its annual gross revenue from cashing checks, must register annually with the Department.

A retail grocery store check casher is subject to the provisions of sections 301(b)(4), 304(c)(3), 503, 507 and 509 of the Check Casher Licensing Act.

Restrictions

Section 505 of the Check Casher Licensing Act. No check casher shall at any time cash or advance any money on a postdated check. No check casher shall engage in the business of transmitting money or receiving money for transmission, unless licensed under the Money Transmitter Act – Act 129.

Refer to Section 503 of the Check Casher Licensing Act for allowable fees and charges for cashing a check.

Retail Grocery Store Check Casher Branch Registration

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Annual registration fees; renewals

Section 1101 of the Check Casher Licensing Act. A fee of $100 must accompany the application for registration. Checks or money orders should be made payable to the Pennsylvania Department of Banking and Securities. By regulation, there can be no abatements granted on registration fees for registrations issued after the start of the May 1 registration year. If a registration is surrendered,revoked, or suspended prior to its expiration date, the registration fee cannot be refunded in whole or in part.

An annual fee of $100 must accompany renewal registrations. The renewal registration shall be effective from May 1 or upon the Department’s issuance of written notification that the entity has been registered by the Department as a retail grocery store check casher, whichever is later, through April 30 of the following year.

Other provisions that apply; other laws that may apply

The preceding discussion does not represent a complete analysis of the Check Casher Licensing Act. You are strongly advised to read and review the Check Casher Licensing Act along with Title 10, Pennsylvania Code, Chapter 81 and comply with all provisions when conducting business.

Information about corporate and business registration can be obtained by contacting the Corporation Bureau of the Pennsylvania Department of State, 3rd Floor, North Office Building, Harrisburg, Pennsylvania 17120-0029. The telephone number is (717) 787-1057, TT/Voice 1-800-679-5070 or visits their website at www.dos.pa.gov. An attorney should be able to advise you about federal laws that apply to retail check cashers.

How and Where to file

Please complete Part 2 of this application. Make a copy for your records. Mail the original and any required attachments, along with a check or money order in the proper amount, to the following address:

Pennsylvania Department of Banking and Securities Non-Depository Licensing Office 17 N 2nd St, Ste 1300 Harrisburg, Pennsylvania 17101-2290

Keep Part 1 for your records, as well as the copy of the Check Casher Act.

If you have any questions, please call the Non-Depository Licensing Office weekdays from 8:30 a.m. to 5:00 p.m. at (717) 787-3717, TT/Voice 1-800-679-5070 or visit our web site atwww.dobs@pa.gov.

We look forward to processing your application.

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RETAIL GROCERY STORE CHECK CASHER BRANCH APPLICATION

Part 2

For Official Use Only Registration #

1. Please indicate name of business:

Name of entity:

D/B/A [if applicable]:

Main Office License #:

OFFICIAL LOCATION ($100 LICENSING FEE MUST ACCOMPANY APPLICATION:

Zip: State:

Branch Manager:

Fax Number:

Street Address:

City:

County:

Telephone Number:

2. List complete address where check cashing business will be conducted.

Suite or Room #

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No Yes – please attach proof

3. Information about the branch/office manager of the entity.

List full name, corporate or official title in the business, residence address, residence telephone number, cell phone number and email address of the manager of the proposed licensed location.

Full Name: Title:

Street Address:

City: State: Zip:

Home Phone: Cell Phone:

Email Address:

4. Are you a Retail Food Store licensed/registered as a food establishment as defined inSection 2 of the Food Act (P.L. 421, No 70)?

No Yes - please attach proof

5. Are you a Retail Food Store licensed/registered as a public eating or drinking place asdefined in Section 1 of the Public Eating and Drink Place Law (P.L. 926, No. 369)?

6. Gross Income Revenue for the last calendar year.

7. Total Gross Revenue for cashing checks for the last calendar year

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I understand by submitting this Retail Grocery Store Check Casher Application:

I am agreeing to be bound by the following declaration: "I declare that all of my answers on this Registration Application 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."

I attest that I have read and understand the following (click each link):

1.) Check Casher Act.

2.) Title 10, Pennsylvania Code, Chapter 81

Authorization/Affirmation

Owner, Officer or Partner:

Title:

Name:

Name: Title:

Signature:

Title:

Name:

Signature:

Signature:

Signature:

Title:Name:

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Have you...

Answered all questions or indicated N/A? Checked answers for accuracy? Authorized/Affirmed the application? Attached a copy of the Articles of Incorporation, Operating Agreement and/or Foreign Registration Statement? Attached a copy of the approved fictitious name registration if applicable? Made and retained a copy of the entire application for your records? Enclosed a check for the appropriate amount?

PENNSYLVANIA DEPARTMENT OF BANKING AND SECURITIES NON-DEPOSITORY LICENSING OFFICE 17 N 2ND ST, STE 1300 HARRISBURG, PA 17101-2290

8. Please review before mailing this application.

9. Please mail completed application and all required documentation to:

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