SCHEDULE 6

Form of Statement to be Published by Insurance Companies and Deposit, Provident, or Benefit Societies

*The share capital of the company is _ _ _ divided into _ _ _ shares of _ _ _ each.

The number of shares issued is....

Calls to the amount of .... pounds per share have been made, under which the sum of .... pounds has been received.

The liabilities of the company on the first day of January (or July) were—

Debts owing to sundry persons by the company.

On judgment, £

On specialty, £

On notes or bills, £

On simple contracts, £

On estimated liabilities, £

The assets of the company on that day were

Government securities (stating them)

Bills of exchange and promissory notes, £

Cash at the bankers,

Other securities, £

* If the company has no share capital the portion of the statement relating to capital and shares must be omitted.