Annuity Broker Qualification Declaration Form

OMB 1105-0080

This declaration is to be submitted to determine whether a broker meets the minimum qualifications to be listed as an annuity broker pursuant to Section 11015(b) of Public Law 107-273.

The latest form for Annuity Broker Qualification Declaration Form expires 2022-04-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 1105-0080 Annuity Broker Qualification Declaration Form Form and Instruction
1105-0080 Supporting Statement_121515.doc Supporting Statement A
Annuity Broker Qualification Declaration Form Form and Instruction

All Historical Document Collections

202204-1105-001 Approved without change	Extension without change of a currently approved collection	2022-04-20
201902-1105-002 Approved without change	Extension without change of a currently approved collection	2019-02-26
201512-1105-003 Approved without change	Extension without change of a currently approved collection	2016-01-13
201212-1105-001 Approved without change	Extension without change of a currently approved collection	2012-12-12
200905-1105-001 Approved with change	Revision of a currently approved collection	2009-11-02
200608-1105-001 Approved without change	Revision of a currently approved collection	2006-10-03
200309-1105-001 Approved without change	Extension without change of a currently approved collection	2003-09-25
200303-1105-001 Approved without change	New collection (Request for a new OMB Control Number)	2003-03-10