SEC 1707 Form ADV Part 1B

FORM ADV
Part 1B
Page 1 of 4

Your Name

CRD Number

Date

SEC 801 or 802 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

Item 2

❑ 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
❑ VI
❑ WA
❑ WV
❑ WI

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)

(Number and Street)

(City)
(State/Country)

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: $

(3) Bond Policy Number:

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

Revised 10/2012

.00

❑ Yes

❑ No

(Facsimile Number)

(Zip+4/postal code)

FORM ADV
Part 1B
Page 2 of 4

Your Name

CRD Number

Date

SEC 801 or 802 Number

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

Yes

No

❑

❑

❑

❑

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):

❑ 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

FORM ADV
Part 1B
Page 3 of 4

Your Name

CRD Number

Date

SEC 801 or 802 Number

(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

Investments
Investments

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

I. Custody

(1) Advisory Fees

Do you withdraw advisory fees directly from your clients’ accounts?

If you answered “yes”, respond to the following:

Yes

No

❑

❑

(a) Do you send a copy of your invoice to 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?

❑

❑

Yes

No

(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 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, have you or
a related person engaged any of the following to provide authority permitting each direct payment or
any transfer of funds or securities from the account of the pooled investment vehicle?

Attorney

Independent certified public accountant

Other independent party

Describe the independent party:

Yes

No

❑
❑
❑

❑
❑
❑

FORM ADV
Part 1B
Page 4 of 4

Your Name

CRD Number

Date

SEC 801 or 802 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.

Yes

No

❑

❑

❑

❑

Yes

No

❑

❑

❑

❑

❑

❑

J. 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. Certified Financial Planner (“CFP”)

❑ 2. Chartered Financial Analyst (“CFA”)

❑ 3. Chartered Financial Consultant (“ChFC”)

❑ 4. Chartered Investment Counselor (“CIC”)

❑ 5. Personal Financial Specialist (“PFS”)

❑ 6. 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:

(2) Indicate your IRS Employer Identification Number:

(MM/DD/YYYY)

BOND DISCLOSURE REPORTING PAGE (ADV)
GENERAL INSTRUCTIONS
This Disclosure Reporting Page (DRP ADV) is an ❑ INITIAL OR ❑ AMENDED response used to report details for
affirmative responses to Item 2.C. of Part 1B of Form ADV.
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.
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
“non-registered” by checking the appropriate checkbox.

Your Name

Your CRD Number

ADV DRP - ADVISORY AFFILIATE or MANAGEMENT PERSON
CRD Number

This advisory affiliate or management person is: ❑ a firm ❑ an individual
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. Firm Name: (Policy Holder)
2. Bonding Company Name:
(continued)

BOND DISCLOSURE REPORTING PAGE (ADV)
(continuation)

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 ❑ AMENDED response used to report details for
affirmative responses to Item 2.D. of Part 1B of Form ADV.
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.
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
CRD Number

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

(continued)

JUDGMENT/LIEN REPORTING PAGE (ADV)
(continuation)

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

❑ Exact

❑ Explanation

If not exact, provide explanation:
5. Is Judgment/Lien outstanding?

❑ Yes ❑ No

If no, provide status date (MM/DD/YYYY):
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 ❑ AMENDED response used to report details for
affirmative responses to Item 2.E. of Part 1B of Form ADV.
Check Part 1B item(s) being responded to: ❑ 2.E(1) ❑ 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

CRD Number

This advisory affiliate or management person is: ❑ a firm ❑ an individual
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. Arbitration/Reparation Claim initiated by: (Name of private plaintiff, firm, etc.)
2. Principal Relief Sought (check appropriate item):
❑ Restraining Order
❑ Disgorgement
❑ Civil Penalty(ies)/Fine(s) ❑ Injunction

❑ Money Damages (Private/Civil Claim)
❑ Other
❑ Restitution
(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)

❑ Annuity(ies) - Variable
❑ Direct Investment(s) - DPP & LP Interest(s)

❑ CD(s)
❑ Equity - OTC

❑ Commodity Option(s)
❑ Equity Listed (Common & Preferred Stock)

❑ Debt - Asset Backed
❑ Futures - Commodity

❑ Debt - Corporate
❑ Futures - Financial

❑ Debt - Government
❑ Index Option(s)

❑ Debt - Municipal
❑ Insurance

❑ Investment Contract(s)
❑ 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 (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
❑ Dismissed

❑ Judgment Rendered
❑ Opinion

❑ Settled
❑ Withdrawn

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

❑ Exact

❑ Other
❑ 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, 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).