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Payment Instruments Forms

Notice to Individual - Use of Information

The following items comprise the application package for a license to engage in the business of selling payment instruments:

• California Financial Code - Division 16. Payment Instruments, Chapter 1 - Chapter 11
• FDIC 3064-0006 - Interagency Biographical and Financial Report Form
• FDIC 3064-0006 - Interagency Biographical and Financial Report Form Instructions (Adobe PDF)
• Form 2 - Personal Financial Statement (Rev.01-06) (Adobe PDF)
• Form 3 - Confidential Resume (Rev.02-07) (Adobe PDF)
• California Code of Regulations - Title 10, Chapter 1, Subchapter 80. Payment Instruments
• Form 4025PI - Appointment of Commissioner of Financial Institutions as Agent for Service of Process (Payment Instruments) (Rev.02-07) (Adobe PDF)
• Form 4030PI - Authorization for Release of Information (Payment Instruments) (Rev.02-07) (Adobe PDF)
• Form 5010PI - Application for License under Payment Instruments Law (Rev.02-07) (Adobe PDF)
• Form 5020PI - Agreement of Applicant for License under Payment Instruments Law (Rev.02-07) (Adobe PDF)

Forms needed for fingerprinting are not available on the internet, but may be received by calling Meli Brown at (415) 263-8542 or email at mbrown@dfi.ca.gov.