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| | Balance of Revenue Account carried forward |
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| | Bonus payments made to policyholders in anticipation of a surplus |
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| | Net transfers out of Fund |
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| | Net liabilities under policies — |
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| | Total Net Liabilities (5+6) |
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| | B. Composition of Surplus |
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| | Balance of surplus brought forward unappropriated from last valuation |
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| | Sources of surplus arising in the year — |
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| | Total surplus arising in the year (11 to 17) |
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| | C. Distribution of Surplus |
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| | Bonus payments made to policyholders in anticipation of a surplus (=2) |
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| | Distributed to policyholders — |
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| | Total distributed to policyholders (20 to 22) |
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| | Distributed to shareholders |
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| | Total distributed surplus (23+24) |
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| | Balance of surplus carried forward |
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| | Name and Signature of Actuary : ________________________ |
| Names and Signatures of 2 Directors : ________________________ |
| Name and Signature of Principal Officer : ________________________ |
| Date: ________________________ |
| |