N.J. Admin. Code § Tit. 11, ch. 2, subch. 43, app APPENDIX

Current through Register Vol. 56, No. 23, December 2, 2024
Appendix - APPENDIX

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