Form 2223 form ADV-E

UNITED STATES
SECURITIES AND EXCHANGE COMMISSION

Washington, D.C. 20549

OMB APPROVAL
OMB Number:
3235-0361
Expires:
December 31, 2018
Estimated average burden hours
per response . . . . . . . . . . . . . . .0.05

FORM ADV-E
Certificate of Accounting of Client Securities and Funds in the Possession or Custody of an Investment Adviser
Pursuant to Rule 206(4)-2 [17 CFR 275.206(4)-2]

1.

Investment Adviser Act SEC File Number:
801-

Date examination completed:

2. State Identification Number:

AL
CO
GA
IA
MD
MO
NJ
OH
SC
VT
WI

AK
CT
HI
KS
MA
MT
NM
OK
SD
VI
WY

AZ
DE
ID
KY
MI
NE
NY
OR
TN
VA
PUERTO RICO

AR
DC
IL
LA
MN
NV
NC
PA
TX
WA
Other (specify):

CA
FL
IN
ME
MS
NH
ND
RI
UT
WV

3. Full name of investment adviser (if individual, state last, first, middle name):
4. Name under which business is conducted, if different from above:

5. Address of principal place of business (number, street, city, state, zip code):
INSTRUCTIONS
This Form must be completed by investment advisers that have custody of client funds or securities and that are subject to an annual surprise
examination. This Form may not be used to amend any information included in an investment adviser’s registration statement (e.g., business address).
Investment Adviser
1.
2.

All items must be completed by the investment adviser.
Give this Form to the independent public accountant that, in compliance with rule 206(4)-2 under the Investment Advisers Act of 1940 (the “Act”)
or applicable state law, examines client funds and securities in the custody of the investment adviser within 120 days of the time chosen by the
accountant for the surprise examination and upon such accountant’s resignation or dismissal from, or other termination of, the engagement, or if
the accountant removes itself or is removed from consideration for being reappointed.

Accountant
3.

The independent public accountant performing the surprise examination must submit electronically on the Investment Adviser Registration
Depository:
(i) this Form and a certificate of accounting (i.e., accountant’s report) required by rule 206(4)-2 under the Act or applicable state law within 120
days of the time chosen by the accountant for the surprise examination, and
(ii) this Form and a statement, within four business days of its resignation or dismissal from, or other termination of, the engagement, or removing
itself or being removed from consideration for being reappointed, that includes
(A) the date of such resignation, dismissal, removal, or other termination, and the name, address, and contact information of the accountant,
and
(B) an explanation of any problems relating to examination scope or procedure that contributed to such resignation, dismissal, removal, or
other termination:
THIS FORM MUST BE GIVEN TO YOUR INDEPENDENT PUBLIC ACCOUNTANT

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. Sections 203(c)(1) and 204 of the Advisers Act authorize the Commission to collect the information
on this Form from applicants. See 15 U.S.C. §§ 80b-3(c)(1) and 80b-4. Filing of this Form is mandatory. The principal purpose of this collection of

SEC 2223 (01-13)

FORM ADV-E

PAGE 2

information is to make the examination certificates filed by an accountant pursuant to Rule 206(4)-2(a)(4)(i) under the Adviser Act (after that accountant
has verified by actual examination the securities and funds of clients in the custody of an investment adviser) more accessible for inspection by the
Commission staff and the public and will facilitate verification of compliance with examination requirements. See 17 CFR §275.206(4)-2(a)(4)(i). The
Commission will maintain files of the information on Form ADV-E 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-E, 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. The applicable Private Act system of records is SEC-2, and the routine uses of the records are set forth at 40 FR 39255 (Aug. 27,
1975) and 41 FR 5318 (Feb. 5, 1976).