NEW MEXICO TITLE INSURANCE AGENCY STATISTICAL REPORT SCHEDULE A - STATEMENT OF INCOME AND EXPENSES For the Calendar Year Ending December 31, 20___. AGENCY NAME LICENSE NUMBER ADDRESS CONTACT NAME Check one: INDEPENDENT (NON-AFFILIATED) Title insurance agencies that are independently owned and write title insurance business for one or more title insurers. AFFILIATED Title insurance agencies with 10% or greater ownership by a title insurer, including wholly-owned agencies. DIRECT Agency-type operations performed by the home or branch office of a title insurer. This does NOT include wholly-owned agencies. Part A: Revenue 1. Title insurance written premiums (from Schedule B) 2. Less: Remitted title insurance premiums (from Schedule B) 3. Retained title insurance premiums (from Schedule B) 4. Other income (from Schedule C) 5. Total Revenue Part B: Expenses 1. Employees’ salaries and wages 2. Owners’ and partners’ salaries and wages 3. Employee benefits 4. Rent 5. Insurance 6. Legal expense 7. Licenses, taxes and fees 8. Title plant expense and maintenance 9. Office supplies 10. Depreciation 11. Automobile expense 12. Communication expense 13. Education expense 14. Bad debts 15. Interest expense 16. Employee travel and lodging 17. Loss and loss adjustment expense (from Schedule D) 18. Accounting and auditing expense 19. Public relations expense 20. Other expenses (from Schedule E) 21. Total Expenses Part C: Net Income for Ratemaking Purposes 1. Income (Loss) from Operations Part D: Excluded Expenses 1. NMLTA lobbying expense 2. Direct lobbying expense 3. Political contributions 4. State and federal income tax expense 5. ½ of meals and entertainment expense 6. Penalties 7. Country club dues 8. Salaries in excess of salary cap 9. Other excluded expenses (from Schedule E) 10. Total Excluded Expenses Part E: Net Income 1. Net income as reported on the books of the agency Part F: Equity 1. Total equity as reported on balance sheet of the agency Part G: Number of Employees 1. Total number of employees

NEW MEXICO TITLE INSURANCE AGENCY STATISTICAL REPORT

SCHEDULE A - STATEMENT OF INCOME AND EXPENSES

For the Calendar Year Ending December 31, 20___.

AGENCY NAME

LICENSE NUMBER

ADDRESS

CONTACT NAME

Check one:

INDEPENDENT (NON-AFFILIATED)

Title insurance agencies that are independently owned and write title insurance business for one or more title insurers.

AFFILIATED

Title insurance agencies with 10% or greater ownership by a title insurer, including wholly-owned agencies.

DIRECT

Agency-type operations performed by the home or branch office of a title insurer. This does NOT include wholly-owned agencies.

Part A: Revenue

1.

Title insurance written premiums (from Schedule B)

2.

Less: Remitted title insurance premiums (from Schedule B)

3.

Retained title insurance premiums (from Schedule B)

4.

Other income (from Schedule C)

5.

Total Revenue

Part B: Expenses

1.

Employees’ salaries and wages

2.

Owners’ and partners’ salaries and wages

3.

Employee benefits

4.

Rent

5.

Insurance

6.

Legal expense

7.

Licenses, taxes and fees

8.

Title plant expense and maintenance

9.

Office supplies

10.

Depreciation

11.

Automobile expense

12.

Communication expense

13.

Education expense

14.

Bad debts

15.

Interest expense

16.

Employee travel and lodging

17.

Loss and loss adjustment expense (from Schedule D)

18.

Accounting and auditing expense

19.

Public relations expense

20.

Other expenses (from Schedule E)

21.

Total Expenses

Part C: Net Income for Ratemaking Purposes

1.

Income (Loss) from Operations

Part D: Excluded Expenses

1.

NMLTA lobbying expense

2.

Direct lobbying expense

3.

Political contributions

4.

State and federal income tax expense

5.

½ of meals and entertainment expense

6.

Penalties

7.

Country club dues

8.

Salaries in excess of salary cap

9.

Other excluded expenses (from Schedule E)

10.

Total Excluded Expenses

Part E: Net Income

1.

Net income as reported on the books of the agency

Part F: Equity

1.

Total equity as reported on balance sheet of the agency

Part G: Number of Employees

1.

Total number of employees

[13.14.16.9 NMAC – Rp, 13.14.16.9 NMAC, 1/1/2021]