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Viatical Settlement Investment Contracts - Registration For Exemption Form. This is a Mississippi form and can be use in Blue Sky Secretary Of State.
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Tags: Viatical Settlement Investment Contracts - Registration For Exemption, V902, Mississippi Secretary Of State, Blue Sky
VIATICAL SETTLEMENT INVESTMENT CONTRACTS
REGISTRATION FOR EXEMPTION
(FORM V902)
Please complete this application and return it with the filing fee of $500 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:
Date of Birth
Social Security Number
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 investment contracts
you will be offering:
1
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Marketing and Sales Material
Please attach all marketing material you intend to use including, but not 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 Article 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 attachments 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 notify the Business
Regulation and Enforcement Division of the Office of the Mississippi Secretary 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 Comm'n Expires:
SEAL
2
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