Fillable Original / Amended Financial Affairs Division Arizona Department (Arizona)

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Original / Amended Financial Affairs Division Arizona Department (Arizona)

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Original / Amended
Financial Affairs Division
Arizona Department of Insurance
100 North 15th Avenue, Suite 102
Phoenix, AZ 85007-2624
LIFE SETTLEMENT PROVIDER
REPORT OF STOCKHOLDERS/OWNERS
Life Settlement Provider/Applicant Name Federal Employer Identification
Number (FEIN)
Complete the following table with information for each partner, officer, employee (who shall act under the
provider’s certificate of authority) and owner. If the provider/applicant’s stock is publicly traded, omit
information for stockholders owning less than 10% of the shares of stock. ARS § 20-3202(B).
Pursuant to ARS § 20-3202(C), you must provide an updated version of this form within 30 days of a change to the
information provided.
First Name Middle Name Last Name
City and State of
Residence
%
Ownership
___________________________
Date
_________________________________________
_______________________________________________________
Signature
_______________________________________________________
Printe Nadme
Form E-LSP2 (v. 20180716)
Title
TOTAL (must not exceed 100):
0
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Original Amended Financial Affairs Division Arizona Department (Arizona)

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Completed 12 August 2020

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