Understanding the nuances of regulatory compliance is paramount for institutions offering donor annuity agreements, and a critical component of this understanding involves the A3 1209 form, known formally as the "Sworn Statement in Lieu of Annual Statements for Issuers of Donor Annuity Agreements." This form, which originates from the Office of Insurance Regulation's Specialty Product Administration, serves as a declaration by issuers that they have fulfilled the obligations mandated by specific legal and administrative codes. It requires detailed information about the issuing institution, including its name, contact details, and Federal Employer Identification Number (FEIN). Additionally, the form demands a sworn statement by designated officers of the donor annuity issuer, attested by a notary public, affirming the issuer's compliance with Section 627.481, FS., and Chapter 69O-202, Florida Administrative Code, as of the fiscal year-end. The document also accommodates changes like name alteration, FEIN modification, and adjustments in the filing period, further underlining its importance in the regulatory framework. Highlighting features like the ability to save and submit the form electronically underscore the move towards more efficient, digital pathways for compliance. For issuers, understanding every facet of the A3 1209 form is not just about adhering to current regulations; it's about ensuring the ongoing ability to provide vital financial support to their beneficiaries through donor annuities.
| Question | Answer |
|---|---|
| Form Name | A3 1209 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | a3 insurance administration form, fl oir a3, you submit oir make, fl oir donor |
Office of Insurance Regulation
Specialty Product Administration
SWORN STATEMENT IN LIEU OF ANNUAL STATEMENTS
FOR ISSUERS OF DONOR ANNUITY AGREEMENTS
Donor Annuity Issuer's Name:
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Ext: |
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Please indicate whether or not you wish to have clarifications and communications regarding this statement sent to you by internet and if so, what email address they should be sent to:
Check if Yes |
Email Address: |
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Donor Annuity Issuer's Contact Person: |
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Donor Annuity Issuer's FEIN: |
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STATE OF:
COUNTY OF:
,(both printed please), of the above
named issuer, being duly sworn, each deposes and says that they are the above described officers of the said issuer, and that
on, which is the fiscal
Chapter
(Typed Name)
(Signature)
(Title)
(Typed Name)
(Signature)
(Title)
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Subscribed and sworn to before me |
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Subscribed and sworn to before me |
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, 20 |
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Notary Public: |
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Notary Public: |
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Commission |
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Commission |
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Number: |
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Number: |
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Expiration Date: |
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Expiration Date: |
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Personally Known or |
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Personally Known or |
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Produced Identification |
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Produced Identification |
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(Type of Identification Produced) |
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(Type of Identification Produced) |
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For Office Use Only |
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Name Change |
FEIN Change |
Filing Period Change
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SAVE/SUBMIT PAGE
Save - Use this button to save your data to our server. It is strongly recommended that you save your data periodically as you fill in this form. You can still save your data even if you have validation errors appear below.
Submit Final - Use this button if you have entered all the required information and want to submit this data to our server. If you have validation errors, they must be corrected before being able to submit the form data. Once you successfully submit the form data, you can no longer make changes.
When you have completed a form and selected "Submit Final," your report form is uploaded as a "Completed" document to your Component List; this does not submit the report to the Office of Insurance Regulation. Upon completion of all required items, the "Begin Submission Process" button (bottom right of the screen) will activate.
You must select and complete the "Begin Submission Process" to successfully submit your entire filing to OIR.
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