Form Fis 0565 - Statement Demonstrating Eligibility For Registration By Notification

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This form is issued under Act 265, PA 1964, as amended.
FIS 0565 (5/04) Office of Financial and Insurance Services
You must complete and submit this form if you wish to make
an application for registration under Section 302 of the Act.
STATEMENT DEMONSTRATING ELIGIBILITY FOR REGISTRATION BY NOTIFICATION
1. Name of Issuer
If making application under Sec. (a)(1), then answer questions 2 to 6, inclusive.
2. How long has the issuer been in continuous operation?
If less than 5 years, give names of predecessor and state length of time each has been in continuous operation:
3. Has there been any default during the current fiscal year or within the 3 preceding fiscal years in the payment of principal,
interest, or dividends on any security of the issuer, or any predecessor, with a fixed maturity or a fixed interest or dividend
provision?
YES
NO
4. Give the following information as to all securities without a fixed maturity or a fixed interest or dividend provision:
Class of Securities
Book Value
No. of
Maximum Offering
Market Price
Amount ***
Now Outstanding
Per Unit **
Units
Price per Unit *
per Unit *
$
$
$
$
$
Total
*
The maximum offering price or the market price may be on a day selected by the applicant but must be within 30 days
before the date of filing this registration statement.
** Book value must be on a day, selected by the applicant, but must be within 90 days of filing this registration statement
but may be used only if there is neither a readily determinable market price or a cash offering price. (If book value is
used, attach balance sheet from which the same is determined.)
*** The amount extended is the product of either (1) the number of units times the higher of the maximum offering price or
the market price, or (2) the number of units times the book value.
5. If none of the classes of securities now outstanding listed in answer to Question 4 were outstanding securities of the
issuer or any of its predecessors for 3 full years, then complete the schedule below following the footnoted instructions in
Question 4.
Class of Securities
No. of
Maximum Offering
Book Value
Market Price
Amount
Now Outstanding
Units
Price per Unit
Per Unit
per Unit
$
$
$
$
$
Total

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