STATE OF MAINE

PAYROLL PROCESSOR LICENSE APPLICATION

 

BUREAU OF CONSUMER CREDIT PROTECTION

35 STATE HOUSE STATION

AUGUSTA, MAINE 04333-0035

TEL: (207)624-8527

FAX: (207)582-7699

 

 

 

 

 

In accordance with the provisions of 10 M.R.S.A., Chapter 222, §1495 et seq.,

Maine Regulation of Trade--Payroll Processors, application is hereby made for a License as a Payroll Processor.

 

 

 

 

 

 

1.         FULL TRADE NAME (including d/b/a):  ___________________________________________________________________________

 

 

2.         ADDRESS OF LOCATION TO BE LICENSED:  ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

 

TELEPHONE: (         )__________________ FAX: (        )____________________

 

 

3.         ADDRESS OF HOME OFFICE (if different): ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

 

TELEPHONE: (        )_____________________    FAX: (        )____________________

 

 

4.         If the applicant is a sole proprietor or a partnership, complete the following items:

 

DATE & PLACE                      RESIDENCE                                        SOCIAL

NAME                                          OF BIRTH                              ADDRESS                                     SECURITY #

 

(a)  [    ]  Proprietor: 

 

____________________________________________________________________________________________

 

OR

 

(b)  [    ]  Partners: 

 

____________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

 

(Maine Payroll Processor License Application, Page 2 of 4)

 

 

5.         If the applicant is a corporation or a limited liability company, complete the following items:

 

     OFFICERS/MEMBERS                                       DATE & PLACE      RESIDENCE

(TITLE)                   NAME                           OF BIRTH           ADDRESS                                % OWNERSHIP

(a) Officers or

Members:

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

 

(b) Federal I.D. Number:  ________________________________________________________________________

 

(c) Date incorporated or organized___________________ under the laws of the State of _____________________.

 

(d) Include a copy of the charter and by-laws or certificate of formation and membership agreement.

 

(e) If a foreign (out of state) corporation or foreign limited liability company:

 

(1)  Provide proof of filing with the office of Maine Secretary of State as a foreign corporation or L.L.C.

 

(2)  Name and Address of Designated Agent upon whom service of process may be made in this State:

 

__________________________________________________________________________________________

 

6.         Check One:

 

 

[    ]   Applicant is a wholly owned subsidiary of a bank or credit union

[    ]   Applicant is not a wholly owned subsidiary of a bank or credit union

 

7.         Check all that describe the business activities of the applicant:

 

[    ]   Prepares and issues payroll checks

[    ]   Prepares and files state income tax withholding or unemployment insurance reports

[    ]   Collects, holds and turns over to the State Tax Assessor income withholding taxes or unemployment insurance contributions

 

 

8.         Does the applicant have the authority or ability to access, control, direct, transfer or disburse a client’s funds?

 

If YES, respond to all remaining questions.

If NO, skip to question # 11.

 

9.         Include with this application a sample of the periodic report to employer required by Maine law.  This report must include: (1) A sample accounting of funds received, aggregate amounts disbursed for payroll, each category of local, state and federal tax, and unemployment compensation premiums; and (2) A sample quarterly (or more frequent) notice notifying employers how to contact state and federal tax and unemployment insurance authorities to verify receipt of funds.

 

 

 

 

 

 

 

 

 

(Maine Payroll Processor License Application, Page 3 of 4)

 

10.        Determine the amount of surety bond, recovery fund or letter of credit coverage required, using the form below:

 

Jan-Mar Apr-Jun             Jul-Sep            Oct-Dec

 

State Taxes                               ________          ________          ________          ________

 

Federal Taxes                            ________          ________          ________          ________

 

Unemployment Insurance           ________          ________          ________          ________

 

Total:   ________          ________          ________          ________

 

List your appropriate coverage amount, which is the highest quarterly amount shown above or $50,000, whichever is greater, but not to exceed $500,000: $________________.

 

You may satisfy your coverage requirement using one of three options (indicate your option and enclose             appropriate items):

 

a.)  A surety bond in the full amount;

 

 

b.)  An irrevocable letter of credit in the full amount; or

 

 

c.)  A $10,000 surety bond or letter of credit, and a check for 1% of the balance of coverage needed (e.g., $1,000      for each $100,000 of additional coverage required), made payable to the “Treasurer, State of Maine – Payroll      Recovery Fund.”

 

 

11.        Submit one of the following as proof of fidelity coverage as required by 10 MRSA § 1495-D (2):

            Applies only if your company is preparing and issuing payroll checks.

 

[    ] Fidelity Bond                                                          [    ] 3^rd party fidelity coverage

[    ] Employee dishonesty bond                                      [    ] Liability insurance, including crime coverage

 

 

12.        Include the name, title, address, and telephone number of the person to contact for the scheduling of routine compliance examinations:

________________________________________________________________________________________________                                                                                                                                                                         ________________________________________________________________________________________________________________________________________________________________________________________________

 

 

13.        Include the name, title, address, telephone and fax number, and e-mail address of the person to contact if our office receives complaints regarding the activities of your company:

________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________

 

 

14.        Include a check, made payable to “Treasurer, State of Maine”, based upon the Fee            Schedule found below:

 

 

Section 1495-D (4) establishes a license fee is $200, if the applicant serves fewer than 25 employers as payroll processing clients; $500 if the payroll processor has from 25 to 500 employers as payroll processing clients; and $800 for those payroll processors that have more than 500 employers as payroll processing clients.

 

 

(Maine Payroll Processor License Application, Page 4 of 4)

 

 

* * * * * * * * * *

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, residential addresses of officers, and non-public business information) is public information.  Other licensing records to which this information may later be transferred are also considered public records.  Where permitted by law, your company’s name, license number, mailing address and other information listed on this application may be posted on the State’s website.

 

* * * * * * * * * *

Maine law [5 M.R.S.A. §130 (1991)] requires assessment of $20.00 for any check returned by your bank for insufficient funds.

 

* * * * * * * * * *

 

(If a Corporation, affix

corporate seal here)

By:____________________________________

 

 

Printed name: ___________________________

Title: __________________________________

 

 

 

PLEASE MAIL YOUR APPLICATION ADDRESSED AS FOLLOWS:

 

REGULAR MAIL (US Postal Service):                           EXPRESS/OVERNIGHT MAIL (Other than USPS):

            STATE OF MAINE                                                                     STATE OF MAINE

BUREAU OF CONSUMER CREDIT PROTECTION                       BUREAU OF CONSUMER CREDIT PROTECTION

    35 STATE HOUSE STATION                                                        76 NORTHERN AVENUE

     AUGUSTA, ME 04333-0035                                                            GARDINER, ME 04345