Form Rrg-T - Annual Report Of Premiums,taxes,and Fees Of Registered Risk Retention Groups - 2011 Page 3

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NAIC#________ COMPANY NAME____________________________________ 2011 FORM AID AC RRG-T
IS FORM IS TO BE FI GROUP.
**************************************PAYMENTS AND REFUNDS**********************************
1
MAKE CHECK PAYABLE TO THE STATE TREASURER AND ATTACH TO THIS FORM.
CHECKS FOR GROUPS ARE NOT ACCEPTABLE. PAYMENT MUST BE MADE FOR EACH INDIVIDUAL COMPANY.
2
DO NOT TAKE ANY CREDITS FOR PRIOR YEAR OVERPAYMENTS.
3
REFUNDS WILL BE SENT AFTER THE RETURN IS AUDITED.
*********************************************************************************************
AFFIDAVIT
State of ______________________________________________
County of ________________________________________________
Comes _________________________________________________________________________and states on oath that he/she is the
_________________________________________ of_______________________________________________________________________
(Title)
(Name of Company)
and that the foregoing statements are true and correct as shown by the records of said Company.
_________________________________________________________
(ORIGINAL WET SIGNATURE OF OFFICER)
Subscribed and sworn to or affirmed before me, the undersigned Notary Public, on this the _______ day of______
, 20____
_____________________________________________________
NOTARY PUBLIC
My Commission Expires _________________________________
FEDERAL TAX ID NUMBER 71-0847443
ARKANSAS INSURANCE DEPARTMENT
Page 3 of 3
REVISED 2011

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