23 CAR pt. 2, Appendix B. Statement of Changes in Beneficial Ownership of Securities

ARKANSAS INSURANCE DEPARTMENT FORM B STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 1 of Act 107 of 1965 __________________________________________________________________________________________________ (Name of Insurance Company) __________________________________________________________________________________________________ (Name of person whose ownership is reported) __________________________________________________________________________________________________ (Business address of such person: street, city, state, zip code) Relationship of such person to company named above. (See Instruction 5) ________________________________________ Statement for Calender Month of ____________, 19___ CHANGES DURING MONTH AND MONTH-END OWNERSHIP (See instruction 6) _________________________________________________________________________________________________ Date Amount Amount Nature Amount Of Bought Sold Of Owned Title of Security Transaction- or otherwise or otherwise Ownership beneficially Acquired disposed of at end of month (See Instruction 7) (See Instruction 8) (See Instruction 9) (See Instruction 9) (See Instruction 10) (See Instruction 9) _________________________________________________________________________________________________ _________________________________________________________________________________________________ REMARKS: (See Instruction 11) I affirm under penalty of perjury that the foregoing is full, true, and correct. ______________________________________ Signature FORM B INSTRUCTIONS 1. PERSONS REQUIRED TO FILE STATEMENTS. Statements on this form are required to be filed by every person who at any time during any calendar month was directly or indirectly the beneficial owner of more than 10 per cent of any class of equity security of an Arkansas stock insurance company, or a director or officer of the company which is the issuer of such securities, and who during such month had any change in his beneficial ownership of any class of equity security of such company. 2. WHEN STATEMENTS ARE TO BE FILED. Statements are required to be filed on or before the 10th day after the end of each month in. which any change in beneficial ownership has occurred. Statements are not deemed to have been filed with the Commissioner until they have actually been received by him. 3. WHERE STATEMENTS ARE TO BE FILED. One signed copy of each statement sha11 be filed with the Commissioner of Insurance, (address). 4. SEPARATE STATEMENT FOR EACH COMPANY. A separate statement shall be filed with respect to the securities of each company. 5. RELATIONSHIP OF REPORTING PERSON TO COMPANY. Indicate clearly the relationship of the reporting person to the company; for example, "Director", "Director and Vice President", "Beneficial owner of more than 10 per cent of the company's common stock", etc. 6. TRANSACTIONS AND HOLDINGS TO BE REPORTED. Every transaction shall be reported even though purchases and sales during the month are equal or the change involves only the nature of ownership; for example, from direct to indirect ownership. Beneficial ownership at the end of the month of all classes of securities required to be reported shall be shown even though there has been no change during the month in the ownership of securities of one or more classes. 7. TITLE OF SECURITY. The statement of the title of the security shall be such as clearly to identify the security even though there may be only one class; for example, "Class A Common Stock", '16 Convertible Preferred Stock", "5% Debentures Due 1965", etc. 8. DATE OF TRANSACTION. The exact date (month, day and year) of each transaction shall be stated opposite the amount involved in the transaction. 9. STATEMENT OF AMOUNT'S OF SECURITIES. In stating the amount of the securities acquired, disposed of, or beneficially owned, give the face amount of debt securities or the number of shares or other units of other securities. In the case of securities owned indirectly, i. e., through a partnership, corporation, trust or other entity, the entire amount of securities involved in the transaction or owned by the partnership, corporation, trust or other entity shall be stated. The person whose ownership is reported may, if he so desires, also indicate in a footnote, or other appropriate manner, the extent of his interest in the transaction or holdings of the partnership, corporation, trust or other entity. 10. NATURE OF OWNERSHIP. Under "Nature of ownership", state whether ownership of the securities is "direct" or "indirect". If the ownership is indirect, i. e., through a partnership, corporation, trust or other entity, indicate in a footnote, or other appropriate manner, the name or identity of the medium through which the securities are indirectly owned. The fact that securities are held in the name of a broker or other nominee does not, of itself, constitute indirect ownership. Securities owned indirectly shall be reported on separate lines from those owned directly and from those owned through a different type of indirect ownership. 11. CHARACTER OF TRANSACTION. If the transaction was with the issuer of the securities, so state. If it involved the purchase of securities through the exercise of options, so state and give the exercise price per share. If any other purchase or sale was effected otherwise than in the open market, that fact shall be indicated. If the transaction was not a purchase or sale, indicate its character; for example, gift, 5% stock dividend, etc., as the ease may be. The foregoing information may be appropriately set forth in the table or under 'Remarks" at the end of the table. 12. INCLUSION OF ADDITIONAL INFORMATION. A statement may include any additional information or explanation deemed relevant by the person filing the statement. 13. SIGNATURE. If the statement is filed for a corporation, partnership, trust, etc., the name of the organization shall appear over the signature of the officer or other person authorized to sign the statement. If the statement is filed for an individual, it shall be signed by him or specifically on his behalf by a person authorized to sign for him.