CERTIFICATION OF ALLOCATED DEPOSIT-TYPE FUNDS
SPECIAL PURPOSE APPORTIONMENT AND FRAUD ASSESSMENT FOR YEAR ENDED DECEMBER 31, ......
Company Name: ......... Company NAIC No. ......
1. | Annuity Considerations (State Business Page, Line 2, Column 5) | ......... |
2. | Allocated Deposit-Type Deferred Annuity Contract Funds | ......... |
Included in Line 1 above | ||
3. | Prior Year Annuitizations or Immediate Annuities not included | ......... |
in Line 1 above or not previously included in the assessment | ||
base. | ||
4. | Dividends to Policyholders (State Business Page, Line 7.1 + | ......... |
Line 7.3, Column 5) | ||
5. | Net Annuity Considerations Subject to Assessment (Line 1 - | ......... |
Line 2 + Line 3 - Line 4) |
CERTIFICATION
The undersigned certifies that (s)he is authorized to file this information on behalf of (Company Name) and that the information contained herein is correct to the best of his/her knowledge, information and belief.
(Signature) .................................. |
Type or print name ........................... |
Title ........................................ |
N.J. Admin. Code Tit. 11, ch. 2, subch. 43, app APPENDIX