Ill. Admin. Code tit. 50, § 3701.EXHIBIT G
| Viatical Settlement Broker Certification |
| This section should be completed by viatical settlement brokers. | ||||||||||||||||||||
| Please check all forms submitted: | ||||||||||||||||||||
| ¨ | Viatical Settlement Broker Reporting Form – All States and Territories | |||||||||||||||||||
| ¨ | Viatical Settlement Broker Reporting Form – Illinois Transactions Only | |||||||||||||||||||
| I hereby certify that the information contained in the reports indicated above is true and accurate. I acknowledge that providing false and misleading information in the reports, or failing to divulge a fact material thereto, is sufficient grounds for administrative action by the Director and, potentially, applicable criminal penalties. | ||||||||||||||||||||
| Date: / / Signature of individual that prepared reports Print or type name Date: / / Signature of Authorized Representative Print or type name | Date: | / / | Signature of individual that prepared reports | Print or type name | Date: | / / | Signature of Authorized Representative | Print or type name | ||||||||||||
| Date: | / / | |||||||||||||||||||
| Signature of individual that prepared reports | ||||||||||||||||||||
| Print or type name | Date: | / / | ||||||||||||||||||
| Signature of Authorized Representative | ||||||||||||||||||||
| Print or type name | ||||||||||||||||||||
(Source: Added at 39 Ill. Reg. 4975, effective March 23, 2015)