SEC 1707 ADV 1B Redline

FORM ADV
Part 1B
Page 1 of 4

Your Name____________________________________________ ___ CRD Number_____________
Date______________________________________________
SEC 801- Number_________

FORM ADV (Paper Version)
UNIFORM APPLICATION FOR INVESTMENT ADVISER REGISTRATION

PART 1B

You must complete this Part 1B only if you are applying for registration, or are registered, as an investment adviser with
any of the state securities authorities.

Item 1

State Registration

Complete this Item 1 if you are submitting an initial application for state registration or requesting additional state registration(s).
Check the boxes next to the states to which you are submitting this application. If you are already registered with at least one state
and are applying for registration with an additional state or states, check the boxes next to the states in which you are applying for
registration. Do not check the boxes next to the states in which you are currently registered or where you have an application for
registration pending.

AL
AK
AZ
AR
CA
CO

CT
DE
DC
FL
GA
GU

HI
ID
IL
IN
IA
KS

KY
LA
ME
MD
MA
MI

MN
MS
MO
MT
NE
NV

NH
NJ
NM
NY
NC
ND

OH
OK
OR
PA
PR
RI

SC
SD
TN
TX
UT
VT

VA
WA
WV
WI

Item 2

Additional Information

Complete this item 2A. only if the person responsible for supervision and compliance does not appear in Item 1J. or 1K. of
Form ADV Part 1A: 

A. Person responsible for supervision and compliance:

(name)

(title)

(area code)

(telephone number)

(area code)

(facsimile number)

(number and street)

(city)

(state/country)

(zip+4/postal code)

(electronic mail (e-mail) address, if the person has one)
If this address is a private residence, check this box:
B. Bond/Capital Information, if required by your home state.

(1) Name of Issuing Insurance Company:

(2) Amount of Bond: $

.00

(3) Bond Policy Number:

Yes
(4) If required by your home state, are you in compliance with your home
state’s minimum capital requirements?

No

FORM ADV
Part 1B
Page 2 of 4

Your Name
Date

CRD Number _______________
SEC 801-Number
Yes

No

For “yes” answers to the following question, complete a Bond DRP:

C. Has a bonding company ever denied, paid out on, or revoked a bond for you,
any advisory affiliate, or any management person?

For “yes” answers to the following question, complete a Judgment/Lien DRP:

D. Do you have Are there any unsatisfied judgments or liens against you, any advisory affiliate,
or any management person?

For “yes” answers to the following questions, complete an Arbitration DRP:

E. Are you, any advisory affiliate, or any management person currently the subject of, or
have you , any advisory affiliate, or any management person been the subject of, an
arbitration claim alleging damages in excess of $2,500, involving any of the following:

(1) any investment or an investment-related business or activity?

(2) fraud, false statement, or omission?

(3) theft, embezzlement, or other wrongful taking of property?

(4) bribery, forgery, counterfeiting, or extortion?

(5) dishonest, unfair, or unethical practices?

For “yes” answers to the following questions, complete a Civil Judicial Action DRP:

F. Are you, any advisory affiliate, or any management person currently subject to,
or have you, any advisory affiliate, or any management person been found liable in,
a civil, self-regulatory organization, or administrative proceeding involving any
of the following:

(1) an investment or investment-related business or activity?

(2) fraud, false statement, or omission?

(3) theft, embezzlement, or other wrongful taking of property?

(4) bribery, forgery, counterfeiting, or extortion?

(5) dishonest, unfair, or unethical practices?

G. Other Business Activities

(1) Are you, any advisory affiliate, or any management person actively engaged in business as a(n) (check all that apply):

Attorney
Certified public accountant
Tax preparer





Issuer of Securities
Sponsor or syndicator of limited partnerships (or equivalent), excluding pooled investment vehicles
Sponsor, general partner, managing member (or equivalent) of pooled investment vehicles
Real estate adviser

Your Name____________________________________________ ___ CRD Number_____________
Date______________________________________________
SEC 801- Number_________

FORM ADV
Part 1B
Page 3 of 4

(2) If you, any advisory affiliate, or any management person are actively engaged in any business other than those
listed in Item 6.A. of Part 1 A or Item 2.G(1) of Part 1B, describe the business and the approximate amount of time
spent on that business:

H. If you provide financial planning services, the investments made based on those services at the end of your last fiscal year
totaled:

Securities

Non-Securities

Investment








Under $100,000
$100,001 to $500,000
$500,001 to $1,000,000
$1,000,001 to $2,500,000
$2,500,001 to $5,000,000
More than $5,000,000

If securities investments are over $5,000,000, how much?
$____________ (round to the nearest $1,000,000)

Investments








If non-securities investments are over $5,0 00,000, how much?
$____________ (round to the nearest $1,000,000)

I.

Custody

Yes

No

(1) Advisory Fees
Do you withdraw advisory fees directly from your clients’ accounts? If you answered
“yes”, respond to the following:









(a) Do you send a copy of your invoice t o the custodian or trustee at the
same time that you send a copy to the client?



(b) Does the custodian send quarterly statements to your clients showing all
disbursements for the custodian account, including the amount of the advisory fees?

(c) Do your clients provide written authorization permitting you to be paid directly
for their accounts held by the custodian or trustee?


 

(2) Pooled Investment Vehicles and Trusts

( a ) ( i ) Do you or a related person act as general partner, managing member, or person serving
in a similar capacity, for any partnership or trustee for any fund in which your advisory clients are
either partners of the partnership or beneficiaries of the trust pooled investment vehicle for which you
are the adviser to the pooled investment vehicle, or for which you are the adviser to one or more
of the investors in the pooled investment vehicle?

If you answered “yes”, respond to the following:

(a)(ii) As the general partner, managing member, or person serving in a similar
capacity of a partnership, have you or a related person engaged an attorney or an
independent certified public accountant any of the following to provide
authority permitting each direct payment or any transfer of funds or securities from
the partnership account of the pooled investment vehicle?
Yes
No
Attorney
[ ]
[ ]
Independent certified public accountant [ ]
[ ]
Other independent party
[ ]
[ ]

   Describe the independent party:
Description:





  FORM ADV
Part 1B
Page 4 of 4

Your Name
Date

CRD Number _______________
SEC 801-Number

For purposes of this Item 2I.2(a), “Independent party” means a person
that: (A) is engaged by the investment adviser to act as a gatekeeper for
the payment of fees, expenses and capital withdrawals from the pooled
investment; (B) does not control and is not controlled by and is not under
common control with the investment adviser; (C) does not have, and has
not had within the past two years, a material business relationship with
the investment adviser; and (D) shall not negotiate or agree to have
material business relations or commonly controlled relations with an
investment adviser for a period of two years after serving as the person
engaged in an independent party agreement.

(b) Do you or a related person act as investment adviser and a
trustee for any trust, or act as a trustee for any trust in which
your advisory clients are beneficiaries of the trust?
(3) Do you require prepayment of fees of more than $500 per client and for
six months or more in advance.

J.

Yes

No

[ ]

[ ]

If you are organized as a sole proprietorship, please answer the following:

(1) (a)

Have you passed, on or after January 1, 2000, the Series 65 examination?

(b) Have you passed, on or after January 1, 2000, the Series 66 examination
and also passed, at any time, the Series 7 examination?

(2) (a)

Do you have any investment advisory professional designations?

If “no,” you do not need to answer Item 2.J(2)(b).

(b) I have earned and I am in good standing with the organization that issued the following credential:

1.
2.
3.
4.
5.
6.

Certified Financial Planner (“CFP”)
Chartered Financial Analyst (“CFA”)
Chartered Financial Consultant (“ChFC”)
Chartered Investment Counselor (“CIC”)
Personal Financial Specialist (“PFS”)
None of the above

(3) Your social security number:

K. If you are organized other than as a sole proprietorship, please provide the following:
(1) Indicate the date you obtained your legal status. Date of formation: ______________
(MM/DD/YYYY)
(2) Indicate your IRS Employer Identification Number: _________________________

BOND DISCLOSURE REPORTING PAGE (ADV)

GENERAL INSTRUCTIONS

This Disclosure Reporting Page (DRP ADV) is an
INITIAL OR
affirmative responses to Item 2.C. of Part 1B of Form ADV.

AMENDED response used to report details for

Use a separate DRP for each event or proceeding. The same event or proceeding may be reported for more than one person or
entity using one DRP. File with a completed Execution Page.

Your Name

Your CRD Number

Part I

A. The person(s) or entity(ies) for whom this DRP is being filed is
(are): You (the advisory firm)
You and one or more of your advisory affiliates or management persons
One or more of your advisory affiliates or management persons

If this DRP is being filed for an advisory affiliate or management person, give the full name of the advisory affiliate or
management person below (for individuals, Last name, First name, Middle name).

If the advisory affiliate or management person has a CRD number, provide that number. If not, indicate “nonregistered” by checking the appropriate checkbox.

Your Name

Your CRD Number

ADV DRP - ADVISORY AFFILIATE or MANAGEMENT PERSON

CRD Number
individual

This advisory affiliate or management person is: ☐ a firm ☐ an
Registered: ☐ Yes ☐ No

Name (For individuals, Last, First, Middle)

This DRP should be removed from the ADV record because the advisory affiliate(s) or management person(s)
is no longer associated with the adviser.
This DRP should be removed from the ADV record because it was filed in error, such as due to a clerical or dataentry mistake. Explain the circumstances:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
NOTE: The completion of this form does not relieve the advisory affiliate or management person of its obligation to
update its IARD or CRD records.

Part II

1. Firm Name: (Policy Holder)

2. Bonding Company Name:

3. Disposition Type: (check appropriate item)

Denied

Payout

Revoked

4. Disposition Date (MM/DD/YYYY):

Exact

Explanation

If not exact, provide explanation:

5. If disposition resulted in Payout, list Payout Amount and Date Paid:

6. Summarize the details of circumstances leading to the necessity of bonding company action: (your response must fit within
the space provided):

JUDGMENT/LIEN DISCLOSURE REPORTING PAGE (ADV)

GENERAL INSTRUCTIONS

This Disclosure Reporting Page (DRP ADV) is an
INITIAL OR
affirmative responses to Item 2.D. of Part 1B of Form ADV.

AMENDED response used to report details for

Use a separate DRP for each event or proceeding. The same event or proceeding may be reported for more than one person or
entity using one DRP. File with a completed Execution Page.

Your Name

Your CRD Number

Part I

A. The person(s) or entity(ies) for whom this DRP is being filed is
(are): You (the advisory firm)
You and one or more of your advisory affiliates or management persons
One or more of your advisory affiliates or management persons

If this DRP is being filed for an advisory affiliate or a management person, give the full name of the advisory affiliate or
management person below (for individuals, Last name, First name, Middle name).

If the advisory affiliate or management person has a CRD number, provide that number. If not, indicate “nonregistered” by checking the appropriate checkbox.

Your Name

Your CRD Number

ADV DRP - ADVISORY AFFILIATE or MANAGEMENT PERSON

CRD Number
individual

This advisory affiliate or management person is: ☐ a firm ☐ an
Registered: ☐ Yes ☐ No

Name (For individuals, Last, First, Middle)

This DRP should be removed from the ADV record because the advisory affiliate(s) or management person(s) is
no longer associated with the adviser.
This DRP should be removed from the ADV record because it was filed in error, such as due to a clerical or
data-entry mistake. Explain the circumstances:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
NOTE: The completion of this form does not relieve the advisory affiliate or management person of its obligation to
update its IARD or CRD records.

Part II

1. Judgment/Lien Amount:

2. Judgment/Lien Holder:

3. Judgment/Lien Type: (check appropriate item)
Civil

Default

Tax

4. Date Filed (MM/DD/YYYY):

Exact

Explanation

If not exact, provide explanation:
________________________________________________________________________________________________

5. Is Judgment/Lien outstanding?

Yes

No

If no, provide status date (MM/DD/YYYY):

Exact

Explanation

If not exact, provide explanation:
________________________________________________________________________________________________

If no, how was matter resolved? (check appropriate item)

Discharged

Released

Removed

Satisfied

6. Court (Name of Federal, State or Foreign Court), Location of Court (City or County and State or Country) and Docket/Case
Number:

_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

7. Provide a brief summary of events leading to the action and any payment schedule details including current status (if applicable)
(your response must fit within the space provided):

_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

ARBITRATION DISCLOSURE REPORTING PAGE (ADV)

GENERAL INSTRUCTIONS

This Disclosure Reporting Page (DRP ADV) is an
INITIAL OR
affirmative responses to Item 2.E. of Part 1B of Form ADV.
Check Part 1B item(s) being responded to:

2.E(1)

AMENDED response used to report details for

2.E(2)

2.E(3)

2.E(4)

2.E(5)

Use a separate DRP for each event or proceeding. The same event or proceeding may be reported for more than one person or
entity using one DRP. File with a completed Execution Page.

One event may result in more than one affirmative answer to Item 2.E. Use only one DRP to report details related to the same
event. Unrelated arbitration actions must be reported on separate DRPs.

PART I

A. The person(s) or entity(ies) for whom this DRP is being filed is (are):
You (the advisory firm)
You and one or more of your advisory affiliates or management persons
One or more of your advisory affiliates or management persons

If this DRP is being filed for an advisory affiliate or a management person, give the full name of the advisory affiliate or
management person below (for individuals, Last name, First name, Middle name).

If the advisory affiliate or management person has a CRD number, provide that number. If not, indicate “non-registered” by
checking the appropriate checkbox.

Your Name

Your CRD Number

ADV DRP - ADVISORY AFFILIATE or MANAGEMENT PERSON

This advisory affiliate or management person is: ☐ a firm ☐ an individual

CRD Number

Registered: ☐ Yes ☐ No

Name (For individuals, Last, First, Middle)

This DRP should be removed from the ADV record because the advisory affiliate(s) or management person(s) is no
longer associated with the adviser.

This DRP should be removed from the ADV record because it was filed in error, such as due to a clerical or dataentry mistake. Explain the circumstances:
_______________________________________________________________________________________________
NOTE: The completion of this form does not relieve the advisory affiliate or management person of its obligation to
update its IARD or CRD records.

PART II
1. Arbitration/Reparation Claim initiated by: (Name of private plaintiff, firm, etc.)

2. Principal Relief Sought (check appropriate item):
Restraining Order
Civil Penalty(ies)/Fine(s)

Disgorgement
Injunction

Money Damages (Private/Civil Claim)
Restitution

Other
(continued)

ARBITRATION DISCLOSURE REPORTING PAGE (ADV)
(continuation)

Other Relief Sought:

___________________________________________________________________________________________________
___________________________________________________________________________________________________

3. Initiation Date of Arbitration/Reparation Claim (MM/DD/YYYY):
Exact
Explanation

If not exact, provide explanation:

4. Principal Product Type (check appropriate item):

Annuity(ies) - Fixed

Derivative(s)

Investment Contract(s)

Annuity(ies) - Variable
CD(s)
Commodity Option(s)
Debt - Asset Backed
Debt - Corporate
Debt - Government
Debt - Municipal

Direct Investment(s) - DPP & LP Interest(s)
Equity - OTC
Equity Listed (Common & Preferred Stock)
Futures - Commodity
Futures - Financial
Index Option(s)
Insurance

Money Market Fund(s)
Mutual Fund(s)
No Product
Options
Penny Stock(s)
Unit Investment Trust(s)
Other

Other Product Types:

___________________________________________________________________________________________________

5. Arbitration/Reparation Claim was filed with (NASD FINRA, AAA, NYSE, CBOE, CFTC, etc.) and Docket/Case Number:

____________________________________________________________________________________________________

6. Advisory Affiliate’s or Management Person’s Employing Firm when activity occurred which led to the arbitration/reparation
(if applicable):

7. Describe the allegations related to this arbitration/reparation (your response must fit within the space provided):

____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________

8. Current status?

Pending

On Appeal

Final

9. If on appeal, action appealed to (provide name of court) and Date Appeal Filed (MM/DD/YYYY):

(continued)

ARBITRATION DISCLOSURE REPORTING PAGE (ADV)
(continuation)

10. If pending, date notice/process was served (MM/DD/YYYY):

Exact

Explanation

If not exact, provide explanation:

If Final or On Appeal, complete all items below. For Pending Actions, complete Item 14 only.

11. How was matter resolved (check appropriate item):

Consent

Judgment Rendered

Settled

Dismissed

Opinion

Withdrawn

Other

12. Resolution Date (MM/DD/YYYY):

Exact

Explanation

If not exact, provide explanation:

13. Resolution Detail:

A. Were any of the following Sanctions Ordered or Relief Granted (check appropriate items)?

☐ Monetary Award

Amount: $

☐ Settlement

Amount: $

☐ Disgorgement/Restitution

Amount: $

☐ Injunction

B. Other Sanctions:

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

C. Sanction detail: If disposition resulted in a penalty, restitution, disgorgement or monetary compensation, provide total
amount, portion levied against you, or an advisory affiliate or management person, date paid and if any portion of
penalty was waived:

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

14. Provide a brief summary of circumstances related to the action(s), allegation(s), disposition(s) and/or finding(s) disclosed
above (your response must fit within the space provided).