Fs 512 Siq Form PDF Details

The FS 512 SIQ form, mandated by the State of California's Department of Business Oversight, serves as a thorough Statement of Identity and Questionnaire for individuals seeking involvement with companies under its jurisdiction. This comprehensive document requires detailed personal information, including legal name, contact details, and specifics such as sex, hair color, eye color, height, weight, birthdate, and birthplace, ensuring a robust identity verification process. Furthermore, it delves into past residences and employment history over the last decade, demanding transparency about any legal involvements whether through court orders, investigations, or convictions, including misdemeanors and felonies outside of minor traffic citations. The questionnaire extends to query about financial licensure across states, probing any instances of refusal, suspension, or revocation of licenses pertinent to financial business activities. Additionally, it investigates personal financial integrity by inquiring about bankruptcy history, bond issuance rejections or cancellations, and any name changes or use of fictitious business names, aiming to build a profile of reliability and trustworthiness. Tailored for stakeholders in escrow agencies, specific items address roles within the agency and potential conflicts of interest, emphasizing the form's role in safeguarding the financial and operational integrity of businesses within California's regulatory framework. This document not only underscores the importance of transparency and accountability but also highlights the state’s commitment to consumer protection and industry oversight.

QuestionAnswer
Form NameFs 512 Siq Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesstatement of identity form, statement identity pdf, department identity 512 form, california department identity template

Form Preview Example

STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT

STATEMENT OF IDENTITY AND QUESTIONNAIRE

DBO – FS 512 SIQ (REV. 11-13)

File Number, if any

Licensee (Company Name)

Insert Department of Business Oversight file number, if any, and the name of the licensee (company) to which this Statement of Identity and Questionnaire relates.

Legal Full Name

First Name

Middle Name

Last Name

 

(Do not use initials or nicknames)

 

Position to be filled in connection with the preparation of this questionnaire (e.g., Officer, Director, Manager, etc.).

Sex

 

Hair

Eyes

 

Height

Weight

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birthdate

 

 

 

 

 

 

 

 

Birthplace

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Number

 

 

 

 

 

California Driver's License Number

See Commissioner’s Release 2-G regarding

 

(if none, so state)

 

 

 

whether furnishing the social security number is

 

 

 

 

 

 

 

 

 

 

mandatory or voluntary and for a description of the

 

 

 

 

 

 

 

 

 

 

use made of that information.

 

 

 

 

 

 

 

 

 

 

 

 

 

Residence

 

 

 

 

 

 

 

Business

 

 

 

Phone Number

 

 

 

 

 

 

 

Phone Number

 

 

 

 

Email

 

 

 

 

 

 

 

Hours of Employment

 

 

 

Address

 

 

 

 

 

 

 

 

(e.g., 8:00 a.m. to 5:00 p.m.)

 

 

 

 

FS 512 SIQ (Rev. 11/13)

1

Insert Full Name

Insert Licensee

of Individual: _______________________

(Company Name):

1.Residence addresses for the last 10 years:

From

To

 

Street

 

City

State

Zip Code

 

 

 

 

 

 

 

 

 

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attach separate schedule if space is not adequate.

2.Employment for the last 10 years:

From

To

 

Employer Name and Address

 

Occupation and Duties

 

 

 

 

 

 

 

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attach separate schedule if space is not adequate.

FS 512 SIQ (Rev. 11/13)

2

Insert Full Name

Insert Licensee

of Individual: _______________________

(Company Name):

3.a. Have you ever been named in any order, judgment or decree of any court or any governmental agency or administrator, temporarily or permanently restraining or enjoining you from engaging in or continuing any conduct, practice or employment?

Yes

If the answer is "Yes", give details:

No

Attach a copy of any order, judgment or decree.

b.Are you currently, or have you been within the last ten years, under federal, state or local investigation for possible violation of any law, ordinance, or licensing or regulatory scheme?

Yes

If the answer is "Yes", give details:

No

4.a. Are you currently licensed to engage in financial business in this state or any other state?

Yes

No

Financial business means securities broker-dealer or agent, investment adviser or investment adviser representative, financial planner, insurance agent, escrow agent, finance lender or broker, mortgage lender or servicer, real estate broker, payday lender, financial institution, bill payer or prorater, commodity sales person, certified public accountant, or any other business involving investment or financial transactions.

If the answer is "Yes", describe in the chart below the following for each license:

License Period

 

License

 

 

Type of License/Business

 

Name and Address of Licensing Entity

 

 

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From:

 

 

 

 

 

 

 

To:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From:

 

 

 

 

 

 

 

To:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attach separate schedule if space is not adequate.

b.Have you ever been refused a license to engage in any business in this state or any other state, or has any such license ever been suspended, revoked, or surrendered subject to a settlement, or any other similar action?

Yes

If the answer is "Yes", give details:

No

FS 512 SIQ (Rev. 11/13)

3

Insert Full Name

Insert Licensee

of Individual: _______________________

(Company Name):

Attach a copy of any settlement.

5.Have you ever been convicted of or pleaded nolo contendere to a misdemeanor or felony other than minor traffic citations that do not constitute a misdemeanor or felony offense?

"Convicted" includes a verdict of guilty by judge or jury, a plea of guilty or of nolo contendere or a forfeiture of bail. All convictions must be disclosed even if the plea or verdict was thereafter set aside and the charges against you dismissed or expunged or if you have been pardoned. Convictions occurring while you were a minor must be disclosed unless the record of conviction has been sealed under Section 1203.45 of the California Penal Code or Section 781 of the California Welfare and Institution Code.

Yes

If the answer is "Yes", give details:

No

Attach a copy of any order, judgment or decree. If a conviction was entered under Section 23152(a) of the Vehicle Code, attach a written declaration stating whether drugs were involved.

6.Have you ever been a defendant in a civil court action other than divorce, condemnation or personal injury?

Yes

No

If the answer is "Yes", please complete the following:

Date of suitLocation of court

Nature of suit

Attach a copy of any order, judgment or decree.

7.Have you ever been a subject of a bankruptcy or a petition in bankruptcy?

Yes

If the answer is "Yes", give date, title of case, location of bankruptcy filing:

No

8.Have you ever been refused a bond, or have you ever had a bond revoked or canceled?

Yes

If the answer is "Yes", give details:

No

FS 512 SIQ (Rev. 11/13)

4

Insert Full Name

Insert Licensee

of Individual: _______________________

(Company Name):

 

 

 

 

 

 

 

 

9.Have you ever changed your name including a woman’s maiden name, or ever been known by any name other than that herein listed?

Yes

No

If so, explain. Change in name through marriage or court order and exact date of each name change must be listed.

Prior Name

Date of Name Change

__________________________________________

___________________________________

__________________________________________

___________________________________

10.Have you ever done business under a fictitious firm name either as an individual or in any form of business, e.g., partnership, limited liability company, corporation or other?

Yes

If the answer is "Yes", give details:

No

The following questions must be answered by all persons submitting this questionnaire in connection with an

ESCROW AGENT’S LICENSE.

11.In what capacity will you be employed?

(e.g., Clerk, Escrow Officer, Manager, Officer, Director, etc.)

12.Do you expect to be a party to, or broker or salesman in connection with escrows conducted by the escrow company which is employing you?

Yes

If the answer is "Yes", give details:

No

This statement will be considered confidential information and will be filed and maintained as part of the confidential records not subject to public inspection.

FS 512 SIQ (Rev. 11/13)

5

VERIFICATION

I, the undersigned, state that I am the person named in the foregoing Statement of Identity and Questionnaire; that I have read and signed said Statement of Identity and Questionnaire and know the contents thereof, including all exhibits attached thereto, and that the statements made therein, including any exhibits attached thereto, are true, and that I have not omitted any information needed to make this document true.

This verification may be made either before a Notary Public or as a declaration under penalty of perjury. This form MUST be executed before a Notary Public if it is executed OUTSIDE the State of California.

I certify/declare under penalty of perjury that the foregoing is true and correct.

Executed at

(City)

State of

)

 

 

 

 

 

 

 

 

County of

)

Date

 

, 20

 

at

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Signature of Individual)

 

 

 

Subscribed and sworn to before me

 

 

 

___________________ ______, 20______

__________________________________

Notary Public in and for said County and State

 

 

(County)

(State)

this

 

day of

, 20________.

 

 

 

 

 

(Print Name)

 

 

 

(Signature of Individual)

FS 512 SIQ (Rev. 11/13)

6

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This document needs some specific details; in order to ensure consistency, make sure you take heed of the next recommendations:

1. For starters, once filling in the california siq, beging with the form section containing following fields:

Filling in section 1 of state california siq sample

2. Right after the previous part is done, go to type in the relevant details in all these - Position to be filled in, California Drivers License Number, Hours of Employment eg am to pm, and Business Phone Number.

Part no. 2 in filling in state california siq sample

3. Completing Insert Full Name of Individual, Residence addresses for the last, Insert Licensee Company Name, From, Street, City State Zip Code, and Present is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Step no. 3 in completing state california siq sample

4. Now fill in this fourth segment! In this case you've got all these From, Employer Name and Address, Occupation and Duties, Present, Attach separate schedule if space, and FS SIQ Rev form blanks to complete.

Step number 4 of filling out state california siq sample

5. This form has to be finalized by dealing with this segment. Here you will see an extensive set of fields that need accurate details to allow your document usage to be faultless: Insert Full Name of Individual, Insert Licensee Company Name, a Have you ever been named in any, Yes, Yes, and a Are you currently licensed to.

state california siq sample writing process explained (part 5)

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