2011 Form Aid Ac Ci-T - Annual Report Of Premiums, Taxes, And Fees Of All Captive Insurance Companies - Arkansas Insurance Department Page 5

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COMPANY NAME__________________________________
2011 FORM AID AC CI-T
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 SIGNATURE OF OFFICER)
SUBSCRIBED AND SWORN TO OR AFFIRMED BEFORE ME, THE UNDERSIGNED NOTARY PUBLIC, ON THIS THE
________________ DAY OF _______________________, 20_____.
____________________________________
_______________________________________________
MY COMMISSION EXPIRES
NOTARY
ARKANSAS INSURANCE DEPARTMENT
Page 3 of 3
Revised 2011
FEDERAL TAX ID NUMBER 71-0847443

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