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Request For Designation As An Exempt Organization Pursuant To Subdivision Form - State Of California Department Of Corporations

California Code of Regulations

Page 1 of 2

Any organization which desires to be designated as one entitled to the exemption for the offer and sale of

life income contracts pursuant to Subdivision (k) of Section 25100, and which is not within the class

designated in Section 260.100 of these rules, may apply to the Commissioner for such a designation by

order, on the following form:

File No._______________________________________

(Insert file number of previous filings

before the Department, if any.)

Fee: $50

Date of Request________________________________

DEPARTMENT OF CORPORATIONS

STATE OF CALIFORNIA

Request for designation as an exempt organization pursuant to Subdivision (k) of Section 25100 of the

Corporate Securities Law of 1968.

1. _____________________________________________________________

(Name of Applicant)

2. _____________________________________________________________

(Principal business address of applicant)

3. _____________________________________________________________

(State whether applicant is a corporation, trust or other entity)

4. Is applicant organized exclusively for educational, benevolent, fraternal, religious, charitable,

social, or reformatory purposes and not for pecuniary profit?

5. _____________________________________________________________

(Name and address of person to whom correspondence regarding

this request for designation should be addressed.)

6. Describe briefly the type of activities engaged in by the applicant.

7. There are attached hereto as exhibits, if applicable, the following which are hereby incorporated by

reference:

A. Financial statements, including a balance sheet of recent date and a profit and loss statement

for each of the three fiscal years preceding the date of the balance sheet. The balance sheet and

profit and loss statements should reflect all assets acquired from donors of property in

consideration of the payment to the donor or other persons of income or specified periodic

payments.

B. A list containing the complete names and other business affiliations of the directors, officers,

trustees and/or other persons who will be charged with the activities and operation of the

applicant.

C. A statement setting forth the scope and nature of any investment advisory services that the

applicant has utilized or proposes to utilize, or (if no such services are utilized) the investment

experience of the persons to manage the investment portfolio.

07/03/13

Request For Designation As An Exempt Organization Pursuant To Subdivision Form - State Of California Department Of Corporations