Form Fis 0557 - Ace-Net Report Form (Page 2 of 2) in pdf

Form Fis 0557 - Ace-Net Report Form Page 2

FIS 0557

Office of Financial and Insurance Services

MICHIGAN DEPARTMENT OF LABOR & ECONOMIC GROWTH

OFFICE OF FINANCIAL AND INSURANCE SERVICES

Consent to Service of Process

KNOW ALL MEN BY THESE PRESENTS:

That

a/an

(Issuer)

(designate whether issuer is an individual or an organization)

(number, street, city, state and zip code)

for the purpose of complying with the laws of the state of Michigan, hereby irrevocably appoints the

Commissioner of the Office of Financial and Insurance Services of the Michigan Department of

Labor & Economic Growth, or the Commissioner=s successor in office, to be the applicant=s

attorney to receive service of any lawful process in any noncriminal suit, action or proceeding

against applicant, its successor, executor or administrator, which may arise under the Michigan

Uniform Securities Act (being Act 265 of the Public Acts of 1964, as amended) or any rule or order

thereunder after the filing hereof: and the applicant does hereby consent that any such suit, action

or proceeding against applicant may be commenced in any court of competent jurisdiction and

proper venue within the State of Michigan by service of process upon the said Commissioner with

the same force and validity as if served upon the applicant by service personally on its president or

other chief officer, if a corporation, or one of its members if a limited liability company, or on one of

its partners, if a partnership, or on one of its trustees, if a trust, or on the individual, if an individual.

Signature

Title

Date

State of

County of

Subscribed and sworn to before me this

day of

A.D.

Notary Public

County of

State of

Form Fis 0557 - Ace-Net Report Form Page 2