Form E126xs - Application And Order For Release Of Excess Deposit

Department of Insurance

State of Arizona

Financial Affairs Division

2910 North 44th Street, Second Floor

Phoenix, Arizona 85018-7256

Telephone: (602) 912-8420/Fax: (602) 912-8421

Trust Deposit Unit: (602) 912-8427

APPLICATION AND ORDER FOR RELEASE OF EXCESS DEPOSIT

A. Application (To be completed by Applicant)

Application is hereby made in accordance with A.R.S. § 20-588 for release of funds deposited with the Arizona

State Treasurer, which total $_______________________________ in face value, for:

(Name of Company)

(NAIC#)

a ___________________________ corporation, by ________________________________, its duly authorized

officer in his/her capacity as _________________________________, who certifies herein that such funds are in

excess of the required deposit amount of $________________________ and that upon release, the remaining

amount of funds on deposit, measured at the lesser of $____________________ in face value or

$______________________ in current Account Value,* satisfy the deposit requirement.

The properly completed and executed Release Form(s) E126 or E126CD, as applicable is (are) attached which sets

forth the complete description of the funds requested to be released and instructions for their delivery.

Please give notice of the order on this matter by mail delivery to:

_____________________________________________________

Signed: ______________________________________________

Dated: _________________________

B. Order (To be completed by Department of Insurance)

By authority of the Director of Insurance delegated in accordance with A.R.S. § 20-148 and A.R.S. § 20-150, and

in accordance with A.R.S. § 20-588, IT IS HEREBY ORDERED approving the application for release of excess

deposit set forth above, effective this ______ day of ____________________________, ________.

___________________________________________

Assistant Director

Financial Affairs Division

Mailed this _____ day of _______________________, _______ by____________________________________

*Account Value is only applicable to deposits comprised of marketable securities and is defined in the Custody Agreement Form E003 as “the

aggregate of the (a) cash, plus (b) the lesser of the market value, par value or amortized value of each Eligible Security in the Account.”

Form E126XS (Rev. 06/04)

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Form E126xs - Application And Order For Release Of Excess Deposit - 2004