FORM RQV Colorado Division of Securities 1560 Broadway Street, Suite 900 Denver, CO 80202 Colorado File No.: RQV________________________ APPLICATION FOR REGISTRATION Of VIATICAL INVESTMENTS Pursuant to the requirements of section 11-51-304, C.R.S., Rule 51-3.2 and the Interpretive Order dated May 12, 2003, application is made for registration of the described securities and the following information is submitted: 1. 2. ________________________________ _________________________________________________ ________________________________ _________________________________________________ ________________________________ 3. NAME AND ADDRESS OF VIATICAL ISSUER: TITLE OR DESCRIPTION OF VIATICAL INVESTMENT: _________________________________________________ AMOUNT TO BE REGISTERED: Offering Price Amount of Viatical Investment Total Investment Amount $_________________ __________________________ $____________________ 4. Is this an initial Colorado registration or an amendment to increase the size of a previously registered Colorado offering? INITIAL_____ AMENDMENT_____ 5. NAME AND ADDRESS OF UNDERWRITER OR PRINCIPAL BROKER-DEALER (IF ANY): __________________________________________ __________________________________________ __________________________________________ 6. Will these Viatical Investments be sold by an individual acting as a sales representative for the issuer? _____YES_____NO 7. NAME, ADDRESS AND TELEPHONE NUMBER OF ATTORNEY, AGENT OR CORRESPONDENT: _________________________________________________ _________________________________________________ _________________________________________________ 8. Attach Appointment and Consent to Service of Process (Forms U-2 & U-2a); or, if such forms have previously been filed with this office, state the date filed and the documents which they accompanied. ________________________________________________________________________________________ 9. FILING FEE: $_______________(payable to “Colorado State Treasurer”) ________________________________________________ Signature of Applicant ________________________________________________ Type the Name and Title of Applicant (Rev. 7/2006)