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Viatical Settlement Investment Contracts - Registration For Exemption V902 - Mississippi
| Viatical Settlement Investment Contracts - Registration For Exemption Form. This is a Mississippi form and can be used in Securities Blue Sky Secretary Of State . |
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VIATICAL SETTLEMENT INVESTMENT CONTRACTS REGISTRATION FOR EXEMPTION (FORM V902) Please complete this application and return it with the filing fee of $5 00 to: Mississippi Secretary of State Business Regulation and Enforcement Post Office Box 136 Jackson, Mississippi 39205 Company Information Full Name of the Company: Address: Telephone No.: Specify the type of organization of company (corporation, LLC, etc): State of incorporation: Date of incorporation: Agent Information Name of Agents: Social Security Number Date of Birth 1. 2. 3. 4. 5. (Attach additional pages if needed.) Viatical Settlement Investment Contracts Please provide a brief description of the types of viatical settlement i nvestment contracts you will be offering: 1 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2Marketing and Sales Material Please attach all marketing material you intend to use including, but no t limited to, a prospectus, pamphlet, circular, the text of any advertisement, contracts , form letters and any disclosure documents you may use in addition to those required by Ar ticle 9 of the Mississippi Securities Act Rules. Audited Financial Statement Please attach your most recent audited income and expense statement and balance sheet pursuant to Mississippi Securities Act Rule 902(A)(2). Certification I hereby certify that the information on this document and in the attach ments hereto is true and correct. I further certify that I am authorized to submit this form on behalf of the applicant. I understand that I am under a continuing obligation to notif y the Business Regulation and Enforcement Division of the Office of the Mississippi Sec retary of State of any changes in the information provided herein. Signature Date Typed or Printed Name Sworn to and subscribed before me this the day of , 20 . Notary Public My Commn Expires: SEAL 2 American LegalNet, Inc. www.USCourtForms.com
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