Form N-6ei-1 Notification Of Claim Of Exemption Pursuant Page 5

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SIGNATURE
Pursuant to Rule ______________ Under the Investment Company Act of 1940, the undersigned ___________________________
(Name of Separate Account) _____________________________ and ________________________________(Name of Life Insurer)
____________________________________ have caused this Notification of Claim of Exemption to be duly executed on behalf of the
separate account claiming exemption in the city of ______________________________, county of ____________________________,
state of ____________________________ on the ______________________, 20________.
Attest _______________________________________
__________________________________________
(Name)
(Name of Separate Account)
_______________________________________
By _______________________________________
(Title)
(Chairman of the Board of Directors)
Attest _______________________________________
By ________________________________________
(Name)
(Name of Life Insurer)
_______________________________________
By _______________________________________
(Title)
(Director, Trustee or Senior Officer)
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