Viatical Settlement Broker Certification

This section should be completed by viatical settlement brokers.

Please check all forms submitted:

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Viatical Settlement Broker Reporting Form – All States and Territories

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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.