Minn. R. agency 120, ch. 2715, EXEMPTIONS UNDER MINNESOTA STATUTES, SECTION 60A.22, pt. 2715.6401

Current through Register Vol. 49, No. 29, 2025

Part 2715.6401 - FORM A: STATEMENT OF OWNERSHIP

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF EQUITY SECURITIES
(File with Respect to Domestic Stock Insurer Pursuant to Minnesota Statutes, Section 60A.22)
Name of Insurer:
Address:
Name of Person Whose Ownership is Reported:
Address:
Relationship of Such Person to Insurer (See Part 2715.6402, Subpart 4):
Date Indicated Relationship Occurred:

EQUITY SECURITIES BENEFICIALLY OWNED

Title of Security (See Part 2715.6402, Subpart 5)	Nature of Ownership (See Part 2715.6402, Subpart 6)	Amount Beneficially Owned (See Part 2715.6402, Subpart 7)

Remarks (See Part 2715.6402, Subpart 8):

	I affirm under penalty of perjury that the foregoing is full, true, and correct.
Date of Statement:
Where Made:	_____
	(Signature)

Minn. R. agency 120, ch. 2715, EXEMPTIONS UNDER MINNESOTA STATUTES, SECTION 60A.22, pt. 2715.6401

Statutory Authority: MS s 60A.22