INSTRUCTIONS: CONNECTICUT INDIVIDUAL LIFE SETTLEMENT BROKER AFFIDAVIT

Every individual who will act as as a life settlement broker in Connecticut on behalf of a form must complete the affidavit discussed in this article. This document can be obtained from the website of the government of Connecticut.

Connecticut Individual Life Settlement Broker Affidavit Step 1: Enter your last name, first name and middle initial on the first blank line.

Connecticut Individual Life Settlement Broker Affidavit Step 2: Enter your title on the second blank line.

Connecticut Individual Life Settlement Broker Affidavit Step 3: Enter your Social Security number on the third blank line.

Connecticut Individual Life Settlement Broker Affidavit Step 4: Enter your residential address on the fourth blank line.

Connecticut Individual Life Settlement Broker Affidavit Step 5: Enter your residential phone number on the fifth blank line.

Connecticut Individual Life Settlement Broker Affidavit Step 6: Enter your business name on the sixth blank line.

Connecticut Individual Life Settlement Broker Affidavit Step 7: Enter your business address on the seventh blank line.

Connecticut Individual Life Settlement Broker Affidavit Step 8: Enter your business phone number on the eighth blank line.

Connecticut Individual Life Settlement Broker Affidavit Step 9: Answer questions 1 through 3 by checking "Yes" or "No" as applicable. In each case, if "yes," provide an explanation.

Connecticut Individual Life Settlement Broker Affidavit Step 10: On line 4, enter your date of birth.

Connecticut Individual Life Settlement Broker Affidavit Step 11: On line 5, list all residences for the last 10 years, beginning with your current address.

Connecticut Individual Life Settlement Broker Affidavit Step 12: On line 6, indicate your highest level of education completed with a check mark. If you have a degree, enter the type.

Connecticut Individual Life Settlement Broker Affidavit Step 13: On line 7, enter any professional designations or memberships.

Connecticut Individual Life Settlement Broker Affidavit Step 14: On line 8, enter all companies in which you control, directly or indirectly, or own legally or beneficially at least 10% or more of the outstanding stock.

Connecticut Individual Life Settlement Broker Affidavit Step 15: Answer questions 9 through 11 by checking "Yes" or "No" as appropriate.

Connecticut Individual Life Settlement Broker Affidavit Step 16: Provide three references on line 12.

Connecticut Individual Life Settlement Broker Affidavit Step 17: Appear before a notary public, who will affix their seal to the bottom of the form.