N.M. Admin. Code § 13.18.3.25
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 _________________________
N.M. Admin. Code § 13.18.3.25