N.M. Code R. § 13.18.3.20 - AFFIDAVIT

NEW MEXICO CREDITOR-PLACED INSURANCE EXPERIENCE REPORTS FOR THE CALENDAR YEAR ENDING DECEMBER 31, _____

AFFIDAVIT

STATE OF _______________________________

COUNTY OF _____________________________

I,_________________________________________, the (position)__________________________________ of (name of Company) ____________________________________, being duly sworn, deposes and says that on the 31st day of December last, all of the income and expenses of the named company described in Form A, Form B, Form C, and Form D submitted with this Affidavit, together with any related reports, exhibits, schedules and explanations contained in this filing, or annexed to or referred to in this filing, are a full and true statement in accordance with the instructions provided of income and expenses for the year ended on that date, according to the best of my information, knowledge and belief.

_______________________________________________

Signature

SUBSCRIBED AND SWORN TO BEFORE ME

this _____day of ______________________, ________.

_____________________________________________

Notary Public

My Commission Expires _________________________

Notes

N.M. Code R. § 13.18.3.20

1/1/99; Recompiled 11/30/01, Adopted by New Mexico Register, Volume XXIX, Issue 14, July 24, 2018, eff. 7/24/2018