Exhibit 2012-30 Form T-S4, Annual Report of Title Company`s

Exhibit 2012-30
Form T-S4, Annual Report of Title Company’s Officers Authorized to Provide Information
on Agent Financial Matters
Annual Report of Title Company’s Officers Authorized to Provide Information on
Agent Financial Matters
(Form T-S4)
(Pursuant to Sec. 2651.011(b), Tex. Ins. Code)
TITLE COMPANY NAME:
__________________________________________________________
PRIMARY CONTACT NAME AND TITLE:
__________________________________________________________
ADDRESS:
__________________________________________________________
CITY STATE ZIP:
__________________________________________________________
PHONE:
__________________________________________________________
EMAIL:
__________________________________________________________
REPORTING FOR YEAR:
__________________________________________________________
DATE REPORT IS SUBMITTED:
__________________________________________________________
Exhibit 2012-30
Form T-S4, Annual Report of Title Company’s Officers Authorized to Provide Information
on Agent Financial Matters
STATE OF ________________________, COUNTY OF ________________________
_____________________________________________, being first duly sworn upon
his/her oath, deposes and says:
That he/she is an authorized officer of the company named below, that he/she is the
primary contact authorized to make disclosures to the Texas Department of Insurance
regarding financial matters that would reasonably call into question the solvency of a
title agent appointed by the title company as provided for under §2651.011(b) of the
Insurance Code; that the following officers of the corporation are also authorized to
individually make such disclosures; and that the statements contained herein are true
and correct to the best of his/her knowledge and belief.
_________________________________
Name and Title of Officer (Type or Print)
____________________________
Signature of Officer
_________________________________
Name and Title of Officer (Type or Print)
____________________________
Signature of Officer
_________________________________
Name and Title of Officer (Type or Print)
____________________________
Signature of Officer
_________________________________
Name and Title of Officer (Type or Print)
____________________________
Signature of Officer
_______________________________________
SIGNATURE OF PRIMARY CONTACT
Subscribed and sworn to before me this _______ day of _______________, 20____.
_______________________________________
SIGNATURE
_______________________________________, Notary Public
PRINTED NAME
in and for the State of __________________. My commission expires: ____________
Form Number T-S4