1. 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.)

2. 6. Describe briefly the type of activities engaged in by the applicant.
3. 7. There are attached hereto as exhibits, if applicable, the following which are hereby incorporated by reference:
4. 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.
5. 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.
6. 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.

7. D. An opinion of counsel with respect to the tax consequences to the prospective donors of property. The applicant has duly caused this application to be signed on its behalf by the undersigned, thereunto duly authorized.

   _________________________

   (Applicant)

   By _______________________

   (Title)

   I certify (or declare) under penalty of perjury under the laws of the State of California that I have read this application and the exhibits thereto and know the contents thereof, and that the statements therein are true and correct.

   Executed at _______________(Place), on __________(Date ), 20___.

   _________________________

   (Signature)

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 BUSINESS OVERSIGHT 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)

Note: Authority cited: Section 25610, Corporations Code. Reference: Section 25100(k), Corporations Code.

History

1. Amendment of form filed 5-14-69; effective thirtieth day thereafter (Register 69, No. 20).

2. Editorial correction adding Note filed 3-9-83 (Register 83, No. 11).

3. Amendment filed 2-11-85; effective thirtieth day thereafter (Register 85, No. 7).

4. Change without regulatory effect amending form filed 9-25-2002 pursuant to section 100, title 1, California Code of Regulations (Register 2002, No. 39).

5. Change without regulatory effect amending form heading filed 8-13-2014 pursuant to section 100, title 1, California Code of Regulations (Register 2014, No. 33).