Read CPA Intent Form text version

Texas Department of Insurance

Financial Regulation Division, Financial Analysis Section, MC 303-1A 333 Guadalupe St. · Austin, Texas 78701 telephone 512-322-5002 · fax 512-322-5082 ·

2012 CPA Audited Financial Statements ­ Intent Form

(To be filed by Texas Domestics only, on or before December 31, 2012) Information below must be provided: NAIC NO: CONTACT NAME: COMPANY NAME: ADDRESS: CITY STATE ZIP: PHONE: Email: FAX: NAIC GROUP NO:

Complete the following: State of Domicile Name of Officer (Type or Print) Signature of Officer Please complete the information below: 1. To register a CPA: Providing the Accountant information below indicates that you intend to file an Audited Financial Report for 2012. a. Designation of Accountant must be indicated below and filed on or before December 31, 2012:

(The following must be completed)

Title of Officer Date

Name of Firm: Address: City/State/Zip: b. Registration of Accountant (formerly CPA Awareness Letter 1.15(A)§11): A letter signed by the accountant indicating awareness of the requirements of TIC § 401.014 - MUST be attached to this form and filed on or before December 31, 2012. c. Is this the same CPA firm that prepared the 2011 financial statements: Yes No ___

2. To apply for approval to file a combined or consolidated audited financial report: A letter

requesting permission to file consolidated must be filed on or before December 31, 2012. Include a listing of companies in consolidation.

FIN244 REV. 10/12 Page 1 of 1


CPA Intent Form

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