N.M. Admin. Code § 13.3.3.20 - FORM SCBOS (1966 EDITION)

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES

(To be filed with the Department of Insurance pursuant to Section 59A-36-2 NMSA 1978.)

____________________________________________

(Name of insurance company)

____________________________________________

(Name of person whose ownership is reported)

____________________________________________

(Business address of such person) (street) (city) (state) (zip code)

____________________________________________

Social security number

____________________________________________

Relationship of such person to company named above. (See 13 NMAC 3.3.11) [now 13.3.3.11 NMAC]

STATEMENT FOR CALENDAR MONTH OF ________, 19____

CHANGES DURING MONTH AND MONTH-END OWNERSHIP

(See 13 nmac 3.3.12) [now 13.3.3.12 NMAC]

Title Of Security (See 13 NMAC 3.3.13) [now 13.3.3.13 NMAC]

Date of Trans- Action (See 13 NMAC 3.3.14) [now 13.3.3.14 NMAC]

Amount Bought or otherwise (See 13 NMAC 3.3.15) [now 13.3.3.15 NMAC]

Amount Sold or otherwise (See 13 NMAC 3.3.15) [now 13.3.3.15 NMAC]

Nature Of Ownership (See 13 NMAC 3.3.16) [now 13.3.3.16 NMAC]

Amount Owned beneficially at end of month (See 13 NMAC 3.3.15) [now 13.3.3.15 NMAC]

REMARKS: (See 13 NMAC 3.3.17) [now 13.3.3.17 NMAC]

____________________________________________

Date of statement

I affirm under penalty or perjury that the foregoing is full, true and correct.

____________________________________________

Signature

____________________________________________

Signature guaranteed

Notes

N.M. Admin. Code § 13.3.3.20

7/1/97; Recompiled 11/30/01