Credit annual compliance certificate: Statement of personal information template

As part of your annual compliance certificate, you must include a statement of personal information for any person who has become a fit and proper person of the licensee in the 12 month period before the annual compliance date.

You will be asked to certify that for each newly appointed fit and proper person, you have obtained, and will keep for no less than 7 years from the date on which this annual compliance certificate is lodged, a signed statement of personal information.

You do not have to lodge a copy of the signed statement, however the licensee must make this statement available to ASIC if requested.

You can use this Information Sheet as a template for your records or use another format of your choice as long as all the required information is included.

A failure to comply is a breach of the Electronic Lodgement Protocol.

Download a Word version of this template

Name of person: 

Licences, Authorisation

Within the last 10 years, within Australia or overseas, have you ever been refused the right, or been restricted in the right, to carry on any trade, business or profession for which an authorisation (licence, certificate, registration or other authority) is required by law?

  • Yes
  • No


Within the last 10 years, within Australia or overseas, have you ever been subject to disciplinary action in relation to any such authorisation?

  • Yes
  • No

Within the last 10 years, within Australia or overseas, have you ever been the subject of any investigations or proceedings that are current or pending and which may result in disciplinary action being taken in relation to any such authorisation?

  • Yes
  • No

Within the last 10 years, within Australia or overseas, have you ever been engaged in the management of any companies/businesses that have had a Corporations Act 2001 (or previous corresponding laws) licence cancelled?

  • Yes
  • No

Professional Memberships, Accreditation and Indemnity Insurance

Within the last 10 years, within Australia or overseas, have you ever been reprimanded, or disqualified or removed, by a professional or regulatory body or external dispute resolution scheme in relation to matters relating to your honesty, integrity or business conduct?

  • Yes
  • No

Within the last 10 years, within Australia or overseas, have you ever had any past, present or pending claim made against a professional indemnity insurance policy in relation to advice you have tendered?

  • Yes
  • No

Within the last 10 years, within Australia or overseas, have you ever been refused professional indemnity insurance?

  • Yes
  • No

Within the last 10 years, within Australia or overseas, have you ever been denied accreditation by a lender, mortgage manager or mortgage insurer?

  • Yes
  • No

Within the last 10 years, within Australia or overseas, have you ever had your accreditation cancelled or suspended by a lender, mortgage manager or mortgage insurer, other than for volume reasons, or had your membership of an aggregator or franchise group terminated, or is similar action pending against you?

  • Yes
  • No

Names

Within the last 10 years, within Australia or overseas, have you ever carried on business under any name other than the name or names previously notified to ASIC?

  • Yes
  • No

Within the last 10 years, within Australia or overseas, have you ever been known by any name other than the name or names previously notified to ASIC?

  • Yes
  • No

Offences

Within the last 10 years, within Australia or overseas, have you ever been the subject of administrative, civil or criminal proceedings or enforcement action, which were determined adversely to you (including by you consenting to an order or direction, or giving an undertaking not to engage in unlawful or improper conduct) in any country?

  • Yes
  • No

Solvency

Within the last 10 years, within Australia or overseas, have you ever been declared bankrupt or insolvent under administration, or is there any such action pending?

  • Yes
  • No

Within the last 10 years, within Australia or overseas, have you ever been engaged in the management of any companies/businesses that have had an external administrator appointed, or which have entered into a compromise, or scheme of arrangement, with its creditors?

  • Yes
  • No

Within the last 10 years, within Australia or overseas, have you ever been engaged in the management of any companies/businesses that were declared insolvent?

  • Yes
  • No

Within the last 10 years, within Australia or overseas, have you ever been engaged in the management of any companies/businesses that were declared the equivalent of insolvent under the law of an external territory or country other than Australia?

  • Yes
  • No

Attachment of explanations

If you have answered yes to any question in the Statement of Personal Information, please attach an explanation of each matter including:

  • the judgement and if it has been satisfied
  • for a declaration of bankruptcy or insolvency:
    • date of the declaration and district in which it was made
    • bankruptcy number.

 

For a deed of arrangement, assignment or where creditors have accepted a composition under Part X of the Bankruptcy Act 1966:

  • date of the deed of arrangement, assignment or the special resolution accepting composition and the district in which it was made
  • name and address of the trustee of the deed of arrangement, assignment or of the composition
  • identifying number used in relation to the deed of arrangement, assignment or the composition in the office of the Registrar in Bankruptcy

Responsible managers

Educational qualifications

Complete this information if new person is being nominated as a responsible manager— someone the licensee relies on to demonstrate that it is competent to engage in credit activities.

You must provide details of educational qualifications relevant to the person’s responsibilities for this Australian credit licence.

Institution Course name Year of completion
     
     

Employers

You must provide details of the person’s employers where experience relevant to their responsibilities for this Australian credit licence was gained.

Employer Job title including Division (if applicable) Start and end dates with this employer
     
     

Signature of person
 

Date signed

Download a Word version of this template

More information

  • Go to www.asic.gov.au/credit for the latest information on credit and to download copies of the regulatory guides.
  • Subscribe to ASIC updates on credit at www.asic.gov.au/credit-update.
  • Go to www.asic.au/search to search the Australian Credit Register
  • Information sheet 135 Annual compliance certificates for Australian credit licence holders (INFO 135)
  • Regulatory Guide 206 Credit licensing: Competence and training (RG 206)
  • Regulatory Guide 207 Credit licensing: Financial requirements (RG 207)

This is Information Sheet 138 (INFO 138), issued in January 2011. Information sheets provide concise guidance on a specific process or compliance issue or an overview of detailed guidance.

Search our registers

Use our online services

Find a form

Contact us

Last updated: 20/10/2014 12:00