Form 1105-0080 Annuity Broker Qualification Declaration Form

U.S. Department of Justice
Civil Division

OMB Number 1105-0080
Form Expiration Date ??/??/201?

Appendix to Section 50.24
Declaration
I, __________________________________ , have carefully reviewed the Department of
Justice regulation contained in 28 CFR 50.24 and published in the Federal Register on March 6,
2006, at 71 FR 11158, and I understand the minimum qualifications set forth in 28 CFR 50.24. I
declare that I meet the minimum qualifications for inclusion on the Department of Justice’s list
of annuity brokers. Specifically, I declare each of the following to be true, accurate, correct, and
complete as of the date this Declaration is signed:
a. I am currently licensed by at least one State, the District of Columbia, or a Territory of
the United States as a life insurance agent, producer, or broker;
b. I am currently licensed or appointed by at least one life insurance company to sell its
structured settlement annuity contracts or to act as a structured settlement consultant or
broker;
c. I am currently covered by an Errors and Omissions insurance policy, or an equivalent
form of insurance;
d. I have never had a license to be a life insurance agent, producer, or broker revoked,
rescinded, or suspended for any reason or for any period of time;
e. I have never been convicted of a felony; and
f. I have had substantial experience in each of the past three years in providing structured
settlement brokerage services to or on behalf of defendants or their counsel.
By submitting this Declaration to the Department of Justice, I am agreeing that this
Declaration and the list of brokers each may be made public in its entirety, and I expressly
consent to the release and disclosure of the Declaration and the list.
I declare under penalty of perjury that the foregoing is true, accurate, complete, and
correct. 28 U.S.C. 1746.

Executed on this ________ day of ___________, 2______ .

_______________________________________________
(Signature of Individual Broker Making Declaration)

_______________________________________________
(Print Full Name of Individual Broker Making Declaration)

________________________________________________
(Street or Post Office Box)

________________________________________________
(City, State, and Zip Code)
After completing and signing this Declaration, mail the Declaration to the Torts Branch,
FTCA Staff, Post Office Box 888, Benjamin Franklin Station, Washington, D.C. 20044.

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simpler, you can write to Director, Communications Office; Civil Division; U.S. Department of
Justice; Washington, D.C. 20530. OMB No. 1105-0080. DO NOT MAIL YOUR
COMPLETED DECLARATION TO THIS ADDRESS.