The A3 1209 form is a commonly used form in the business world. This form is used to provide detailed information on a project or situation. The form can be used for a variety of purposes, including problem solving, decision making, and communication. The A3 1209 form is typically filled out by someone with experience in the subject matter area. The A3 1209 form can be a valuable tool for businesses of all sizes. By using the form, businesses can communicate important information to others and document their progress on projects. Additionally, the form can help businesses better understand complex situations and make better decisions. If you're looking for a way to improve your business's communication and decision-making skills, the A
| 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:
Street:
City: |
|
State/Prov: |
|
|
Zip/Postal: |
|
|||
Phone: |
|
Ext: |
|
|
|
Fax: |
|
||
|
|
||||||||
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: |
|
|
Donor Annuity Issuer's Contact Person: |
|
|
|
Donor Annuity Issuer's FEIN: |
|
|
|
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)
|
|
Subscribed and sworn to before me |
|
|
|
|
Subscribed and sworn to before me |
|
|
|
||||||||
This |
|
day of |
, 20 |
|
This |
|
day of |
, 20 |
|
|
||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Notary Public: |
|
|
|
|
|
Notary Public: |
|
|
|
|
||||||
|
|
Commission |
|
|
|
|
Commission |
|
|
|
||||||||
|
|
|
Number: |
|
|
|
|
|
|
Number: |
|
|
|
|
||||
|
Expiration Date: |
|
|
|
|
Expiration Date: |
|
|
|
|
||||||||
|
|
|
Personally Known or |
|
|
|
|
|
Personally Known or |
|
|
|
||||||
|
|
|
Produced Identification |
|
|
|
|
|
Produced Identification |
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
(Type of Identification Produced) |
|
|
|
|
(Type of Identification Produced) |
|
|
|
||||||||
For Office Use Only |
|
Name Change |
FEIN Change |
Filing Period Change
Print this page
Page 1 of 2 |
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.
The session key will expire on: |
Eastern Time |
Save
Submit Final
Page 2 of 2 |