Legal Name of Viatical Settlement Provider:
ATTESTATION OF SUBMITTER:
Name of Person Submitting Annual Statement:
By checking this box, I attest and affirm that I am authorized to submit this annual statement on behalf of the Provider named herein, and that the information included is true, correct and complete to the best of my knowledge and belief. I understand that knowingly providing false or fraudulent information or knowingly making a material misrepresentation in connection with this annual statement or any information or reports required under the Viatical Settlements Act of 2002, K.S.A. 40-5001 et seq., may result, inter alia, in the revocation of the Provider’s license, or imposition of fines and penalties.