Form SEC-2566 ADV-H

OMB APPROVAL
OMB Number:
3235-0538
Expires:
July 31, 2008
Estimated average burden
hours per response. . . . . . . 1.00

Form ADV-H

APPLICATION FOR A TEMPORARY OR CONTINUING HARDSHIP EXEMPTION
Item 1 Type of Exemption
You are (check one):
Requesting a Temporary Hardship Exemption; or
Applying for a Continuing Hardship Exemption
A. If you are requesting a temporary hardship exemption, this Form ADV-H is for your (check one)
Initial SEC Application
Annual Updating Amendment to SEC Registration
Other-Than-Annual Amendment to SEC Registration
B. If you are applying for a continuing hardship exemption, this Form ADV-H is for all filings between the date you file this
form and ________________________________ .
MM / DD / YYYY
Only an adviser that is a “small business” (as defined by SEC rule 0-7) is eligible for a continuing hardship exemption. To
determine whether you are eligible for a continuing hardship exemption, review Item 12 of the Form ADV that you filed most
recently with the SEC to answer the following questions:
Were you required to answer Item 12 of Part 1A of Form ADV?

Yes

No

Did you check “yes” to any question on Item 12 of Part 1A of Form ADV?

Yes

No

If you were not required to answer Item 12 or checked “yes” to any question on Item 12, you are not eligible for a continuing
hardship exemption and must submit electronic filings to the IARD system.

Item 2 Identifying Information
SEC File number:

801 - _______________

CRD Number (if you have one) __________________

A. Your full legal name (if you are a sole proprietor, state your last, first, and middle names):
____________________________________________________________________________
B. Principal Office and Place of Business
Address (do not use a P.O. Box):
____________________________________________________________________________
(number and street)
____________________________________________________________________________
(city)
(state)
(country)
(zip+4/postal code)
If this address is a private residence, check this box:
C. Name and telephone number of the individual filing this Form ADV-H:
____________________________________________________________________________
(name)
(title)
(area code)
(telephone number)

Item 3 Information Relating to the Hardship
A. If you are filing to request a temporary hardship exemption, attach a separate page that:

SEC 2566 (10-03)

Form ADV-H

Page 2

1.

Describes the nature and extent of the temporary technical difficulties when you attempt to submit the filing in electronic
format.

2.

Describes the extent to which you previously have submitted documents in electronic format with the same hardware and
software that you are unable to use to submit this filing.

3.

Describes the burden and expense of employing alternative means (e.g. public library, service provider) to submit the filing
in electronic format in a timely manner.

4.

Provides any other reasons why a temporary hardship exemption is warranted.

B. If you are applying for a continuing hardship exemption, your application will be granted or denied based on the following items.
You should attach a separate page to this Form ADV-H that:
1.

Explains the reason(s) that the necessary hardware and software are not available without unreasonable burden and expense.

2.

Describes the burden and expense of employing alternative means (e.g. public library, service provider) to submit your filings
in electronic format in a timely manner.

3.

Justifies the time period requested in Item 1 of this Form ADV-H.

4.

Provides any other reasons why a continuing hardship exemption is warranted.

Item 4 How to Submit Your Form ADV-H
Sign this Form ADV-H. You must preserve in your records a copy of the Form ADV-H that you file. Mail one manually signed Form
ADV-H and one copy to U.S. Securities and Exchange Commission, Office of Regulations and Examinations, Mail Stop 0-25, 450 Fifth
Street, N.W., Washington, DC 20549.

Item 5 Execution
I, the undersigned, have signed this Form ADV-H on behalf of, and with the authority of, the adviser requesting a temporary hardship
exemption or applying for a continuing hardship exemption. The undersigned and the adviser represent that the information and statements
made in this ADV-H, including any other information submitted, are true. The undersigned and the adviser further agree to waive any
claim against the administrator of the IARD for errors made in good faith that may occur when converting to electronic format this Form
ADV-H or any paper filing made in reliance of a continuing hardship exemption.
Signature:

_________________________________

Date:

_________________________

Printed Name:

_________________________________

Title:

_________________________

PRIVACY ACT STATEMENT. Section 203(c)(1) of the Advisers Act [15 U.S.C. § 80b-3(c)(1)] authorizes the Commission to collect the information required by
Form ADV-H. The Commission collects this information for regulatory purposes, such as processing requests for temporary hardship exemptions and determining
whether to grant a continuing hardship exemption. Filing Form ADV-H is mandatory for investment advisers requesting a temporary or continuing hardship exemption.
The Commission maintains the information submitted on Form ADV-H and makes it publicly available. The Commission may return forms that do not include
required information. Intentional misstatements or omissions constitute federal criminal violations under 18 U.S.C. § 1001 and 15 U.S.C. § 80b-17. The information
contained in Form ADV-H is part of a system of records subject to the Privacy Act of 1974, as amended. The Commission has published in the Federal Register the
Privacy Act System of Records Notice for these records.
SEC’S COLLECTION OF INFORMATION. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid control number. Section 203(c)(1) of the Advisers Act authorizes the Commission to collect the information on this Form from applicants.
See 15 U.S.C. § 80b-3(c)(1). Filing of this Form is mandatory for an investment adviser to request an exemption from the electronic filing requirements. The
principal purpose of this collection of information is to enable the Commission to process requests for temporary hardship exemptions and to determine whether to
grant a continuing hardship exemption. By accepting a form, however, the Commission does not make a finding that it has been completed or submitted correctly.
The Commission will maintain files of the information on Form ADV-H and will make the information publicly available. Any member of the public may direct to the
Commission any comments concerning the accuracy of the burden estimate on page one of Form ADV-H, and any suggestions for reducing this burden. This
collection of information has been reviewed by the Office of Management and Budget in accordance with the clearance requirements of 44 U.S.C. § 3507.