Form V902 - Viatical Settlement Investment Contracts Registration For Exemption

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VIATICAL SETTLEMENT INVESTMENT CONTRACTS
REGISTRATION FOR EXEMPTION
(FORM V902)
Please complete this application and return it with the filing fee of $500 to:
Mississippi Secretary of State
Business Regulation and Enforcement
Post Office Box 136
Jackson, Mississippi 39205
Company Information
Full Name of the Company:
Address:
Telephone No.:
Specify the type of organization of company (corporation, LLC, etc): ____________
State of incorporation:______________
Date of incorporation: ______________
Agent Information
Name of Agents:
Social Security Number
Date of Birth
1.______________________________________________________________________
2.______________________________________________________________________
3.______________________________________________________________________
4.______________________________________________________________________
5.______________________________________________________________________
(Attach additional pages if needed.)
Viatical Settlement Investment Contracts
Please provide a brief description of the types of viatical settlement investment contracts
you will be offering:
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