SEC-777 Form ADV-W

FORM ADV-W (Paper Version)

OMB APPROVAL
OMB Number:
3235-0313
Expires:
Nov. 30, 2013
Estimated average burden
hours per response……………0.50

NOTICE OF WITHDRAWAL FROM REGISTRATION AS AN INVESTMENT
ADVISER
Instructions for Form ADV-W
NOTE: Unless the context clearly indicates otherwise, all terms used in the Form have the same meaning as in
the Investment Advisers Act of 1940 and in the General Rules and Regulations of the Commission thereunder
(17 Code of Federal Regulations 275).
1.

We would like to withdraw from registration as an investment adviser. What do we need to do?
You must determine whether you are filing for partial withdrawal or full withdrawal.
A partial withdrawal is when you are withdrawing from investment adviser registration with some, but not
all, of the jurisdictions where you are registered (or have an application for registration pending). For
example, you would file for partial withdrawal if you are switching from state registration to SEC
registration (or vice versa). Similarly, you would file for partial withdrawal if you are a state-registered
adviser and are withdrawing from some, but not all, of the states with which you are registered (or have an
application for registration pending).
A full withdrawal is when you are withdrawing from all of the jurisdictions with which you are registered
(or have an application pending).
If you are filing for partial withdrawal and switching from SEC to state registration, you must complete the
Status Section, Items 1A through 1D, and the Execution Section. You do not need to complete Items 1E
through 8 of Form ADV-W.
If you are filing for partial withdrawal and switching from state to SEC registration, you must complete the
entire Form ADV-W.
If you are registered only with the state securities authorities and withdrawing from some, but not all, of the
states where you are registered, you must complete the entire Form ADV-W.
If you are filing for full withdrawal, you must complete the entire Form ADV-W.

2.

We are going out of business. Does this change how we would answer particular questions on the Form
ADV-W?
Yes. The purpose of Item 1D is so that we can contact you if the Form ADV-W is deficient or if we have
questions. If you are going out of business, make sure you list in Item 1D an address and phone number at
which we can reach the contact employee.

3.

I am a state registered adviser filing for partial withdrawal. How do I complete Item 2?
If you are a state registered adviser ceasing advisory business in any of the jurisdictions from which you are
withdrawing, check “yes.” On the next line, provide the date on which you are ceasing advisory business in
these jurisdictions (however, if you cease conducting advisory business on different dates in different
jurisdictions, you must complete a separate Form ADV-W for each different date). The date you provide in this
blank must be on or before the date you file Form ADV-W. Then, provide the reasons you are filing for
withdrawal (regardless of whether you are filing for partial or complete withdrawal).
You are permitted to “post-date” the Form ADV-W to December 31 anytime between November 1 and
December 31. You are permitted to enter a cease date of December 31 to avoid being charged state renewal
fees in jurisdictions from which you are withdrawing (during the last part of December each year the IARD
suspends filing operations for several days to process renewals of state registrations and state notice filings; and

SEC777 (11-10)

Instructions for Form ADV-W

Page 2

you are unable to submit any filings during that time). However, you cannot enter any date other than December
31, and you can only enter a December 31 cease date after November 1.
4.

I have completed Form ADV-W and filed it with the SEC. When will it become effective?
Your Form ADV-W will become effective when it is filed with the SEC. However, your Form ADV-W will not
be deemed “filed” until the SEC receives it and determines that it is not deficient. The effective date of a Form
ADV-W filed with the state securities authorities may be different.

5.

How should I file my Form ADV-W?
You are required to file Form ADV-W electronically on the IARD.
In the event you are unable to submit an electronic filing, you must apply for a temporary or continuing hardship
exemption pursuant to rule 203-3. If you can rely on a temporary or continuing hardship exemption, you must
mail one manually signed Form ADV-W and one copy to: IARD Document Processing, FINRA, P.O. Box
9495, Gaithersburg, MD 20898-9495.
Whether you file on the IARD or are permitted to submit paper filings, you must preserve in your records a copy
of the Form ADV-W that you file with the SEC.

6.

What are the Schedules to Form ADV-W?
Form ADV-W contains two Schedules, Schedule W1 and W2. Your answers to Form ADV-W will determine
whether you are required to complete both Schedules, or only Schedule W1.
Schedule W1 is a “continuation page” for Item 5 and a “response page” for Item 8. The names of individuals
listed on Schedule W1 must be given in full. If you have assigned advisory contracts to another person (as
indicated on Item 5 of Form ADV-W), you must complete Section 5 of Schedule W1. If you are filing for full
withdrawal or you are a state-registered investment adviser, you must provide the name of each person who has
or will have custody or possession of your books and records, and each location where the records are or will be
kept (Item 8). You may have to complete multiple Schedule W1s, depending on the number of persons who
have or will have custody or possession of your books and records and/or the number of locations where your
records are or will be kept. Instruction number seven, below, provides several examples that should help you
properly respond to Item 8 to Form ADV-W.
Schedule W2 requires basic financial information relating to your investment advisory business. If you check
“yes” to Items 3, 4, or 6, you are required to complete Schedule W2.

7.

Questions about Item 8. The following examples are intended to assist you in completing Section 8 of Schedule
W1 for any persons who have or will have custody of your books and records, and the location(s) at which those
records are or will be kept.
a.

After I withdraw from registration, two persons (Persons A and B) will have custody of my books and
records, but my books and records will be kept at a single location. How should I complete the Schedule
W1?
You would complete two Schedules W1. The first would list Person A, and the location at which your
books and records will be kept. You would complete a second Schedule W1 that would list Person B, and
would list (again) the location at which your books and records will be kept.

b.

After I withdraw from registration, only one person will have custody of my books and records, but they
will be kept at three locations (Locations X, Y and Z). How should I complete the Schedule W1?
You would complete three Schedules W1. The first would list the person that will have custody of your
books and records, and Location X. The second Schedule W1 would list (again) the person that has or will
have custody of your books and records, and Location Y. The third Schedule W1 would list (again) the
person that has or will have custody of your books and records, and Location Z.

Instructions for Form ADV-W
c.

Page 3

After I withdraw from registration, two people (Persons A and B) will have custody of my books and
records, and my books and records will be kept at two locations (Locations Y and Z). Each person would
have custody of the books and records that are kept at both locations. How should I complete the Schedule
W1?
You would complete four Schedules W1. The first would list Person A and Location Y. The second
Schedule W1 would list (again) Person A, and would list Location Z. The third Schedule W1 would list
Person B and Location Y, and the fourth Schedule W1 would list Person B and Location Z. On each
Schedule W1, you should briefly describe the records that are kept at each location (e.g., business and
trading records from 1996 through 1999).

8.

Who should sign the Form ADV-W?
Copies of the Form ADV-W you file with the SEC must be executed by a person you have authorized to file the
Form. If you are a sole proprietor, you must sign the Form; if you are a partnership, a general partner must sign
the Form in the name of the partnership; if you are an unincorporated organization or association that is not a
partnership, the managing agent (an authorized person who directs or manages or who participates in the
directing or managing of its affairs) must sign the Form in the name of the organization or association; if you are
a corporation, a principal officer duly authorized must sign the Form in the name of the corporation. If an
officer of any entity is signing the Form, the officer’s title must be given.

9.

What if I need more space to provide additional information?
If you are filing electronically, add any additional information in the text box asking you to “describe the books
and records kept at this location.” If you are filing on paper, use the reverse side of Schedule W1 to provide any
additional information.

10. What if I do not follow these instructions when completing the Form ADV-W?
If you do not prepare and execute the Form ADV-W as required by these instructions, SEC staff may return the
form to you for correction. The SEC’s acceptance of the Form, however, is not a finding that you have filed the
Form ADV-W as required or that the information submitted is true, correct or complete.

PRIVACY ACT STATEMENT. Section 203(h) of the Advisers Act [15 U.S.C. §80b-3(h)] authorizes the Commission to collect the information
required by Form ADV-W. The Commission collects this information for regulatory purposes, such as reviewing an adviser’s application to
withdraw. Filing Form ADV-W is mandatory for an investment adviser to withdraw from registration. The Commission maintains the
information submitted on Form ADV-W 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-W 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(h) of the Advisers Act authorizes the Commission to collect the
information on this Form from applicants. See 15 U.S.C. §80b-3(h). Filing of this Form is mandatory for an investment adviser to withdraw from
registration. The principal purpose of this collection of information is to enable the Commission to verify that the activities of an investment
adviser seeking to withdraw from registration do not require the investment adviser to be registered and to determine whether terms and
conditions should be imposed upon a registrant’s withdrawal. 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-W 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-W, 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.

FORM ADV-W (Paper Version)
NOTICE OF WITHDRAWAL FROM REGISTRATION AS AN INVESTMENT ADVISER
Form ADV-W
You must complete this Form ADV-W to withdraw your investment adviser registration with the SEC or one or more state
securities administrators. We use the term “you” to refer to the investment adviser withdrawing from registration,
regardless of whether the adviser is a sole proprietor, a partnership, a corporation, or another form of organization.
WARNING:

Complete this form truthfully. False statements or omissions may result in administrative, civil or
criminal action against you.

Status
Check the box that indicates what you would like to do:
(i)

Withdraw from registration in all of the jurisdictions with which you are registered (or have an application for
registration pending) (a “full withdrawal”).

(ii)

Withdraw from registration in some, but not all, of the jurisdictions with which you are registered (or have an
application for registration pending) (a “partial withdrawal”).
If you are filing for full withdrawal, you must complete all items of this Form ADV-W. If you are filing for partial
withdrawal, follow the instructions below for the type of partial withdrawal you are filing.

If you are filing for partial withdrawal, indicate the jurisdictions from which you are withdrawing your investment adviser
registration (or application for registration):
(a)

The SEC;
Check this box if you are withdrawing your SEC registration and switching to state registration, or if you are
withdrawing your application for SEC registration. If you check this box (a), you must complete only this
Status Section, Items 1A through 1D, and the Execution Section. Do not complete Item 1E and Items 2
through 8.

(b)

The state(s) for which the box(es) below are checked:
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

VI
VA
WA
WV
WI

If you check this box (b), you must complete all items of this Form ADV-W.

Item 1

Identifying Information

A. Your full legal name (if you are a sole proprietor, your last, first, and middle names):
______________________________________________________________________________
The name you enter here must be the same as the name you entered on your last amended Form ADV. Do not
report a name change on this Form ADV-W.

Form ADV-W

Page 2

B. Your SEC file number (if you are registered with the SEC as an investment adviser):
801- ________________
C. Your CRD number (if you have a number (“CRD number”) assigned by the FINRA’s CRD system):

__________________
If you do not have a CRD number, skip this Item 1C. Do not provide the CRD number of one of your officers,
employees, or affiliates.
D. Name and business address of contact employee:
_______________________________________________________________
(name)
(title)
_______________________________________________________________
(number and street)
_______________________________________________________________
(city)
(state)
(country)
(zip+4/postal code)
___________________________________
(area code) (telephone number)
_________________________________________________
(electronic mail (e-mail) address, if contact employee has one)
The contact employee should be an employee (not outside counsel) who is authorized to receive information and
respond to questions about this Form ADV-W.
E. Principal Office and Place of Business:
Address (do not use a P.O. Box):
_______________________________________________________________
(number and street)
_______________________________________________________________
(city)
(state)
(country)
(zip+4/postal code)
___________________________________
(area code)
(telephone number)
If this address is a private residence, check this box:

Item 2

Status of Advisory Business

A. Have you ceased conducting advisory business in the jurisdictions from which you are
withdrawing?
Yes

No

If yes, provide the date you ceased conducting advisory business in the jurisdictions checked in the status section
above:
___________________________________
MM / DD / YYYY
If you ceased conducting advisory business in these jurisdictions on different dates, you must submit a different
Form ADV-W for each different date on which you ceased conducting advisory business.
B. Reasons for withdrawal: __________________________________________________________
______________________________________________________________________________

Form ADV-W
Item 3

Page 3

Custody

Do you or a related person have custody of client assets?
Yes

No

If yes, provide the following information:
A.
B.
C.
D.

Item 4

Number of clients for whom you have custody of cash or securities:
_________________
Amount of clients’ cash for which you have custody:
$ _____________ .00
Market value of clients’ securities for which you have custody:
$ _____________ .00
Market value of assets other than cash or securities for which you have custody: $ __________ .00

Money Owed to Clients

Have you (i) received any advisory fees for investment advisory services or publications that you have not rendered or
delivered; or (ii) borrowed any money from clients that you have not repaid?
Yes
No
Do not include in your response to this Item 4 any client funds for which you have custody and that you included in
your response to Item 3.
If yes, provide the following information:
A. Amount of money owed to clients for prepaid fees or subscriptions:
B. Amount of money owed to clients for borrowed funds:

Item 5

$ _____________ .00
$ _____________ .00

Advisory Contracts

A. Have you assigned any of your investment advisory contracts to another person?
Yes

No

If yes, provide the following information:
B. Did you obtain the consent of each client prior to the assignment of the client’s contract?

Yes

No

Client consent can be obtained through an actual consent, or can be inferred through the use of a negative
consent.
If you answered “yes” to Item 5A, list on Section 5 of Schedule W1 each person to whom you have assigned any of
your investment advisory contracts. You must complete a separate Schedule W1 for each person to whom you have
assigned any of your advisory contracts.

Item 6

Judgments and Liens

Are there any unsatisfied judgments or liens against you?

Item 7

Yes

No

Statement of Financial Condition

If you answered yes to Items 3, 4, or 6, you must complete Schedule W2, disclosing the nature and amount of your assets
and liabilities and your net worth as of the last day of the month prior to the filing of this Form ADV-W.

Form ADV-W

Item 8

Page 4

Books and Records

This item requires you to list (i) the name and address of each person who has or will have custody or possession of your
books and records; and (ii) each location at which any of your books and records are or will be kept. You must list this
information on Schedule W1, and you must complete a separate Schedule W1 for each person who has or will have custody
of your books and records at each location. The instructions to Form ADV-W contain additional information and examples
to assist you in responding to Item 8.
NOTE: Section 204 of the Advisers Act, or similar state law, requires you to preserve your books and records after
you have withdrawn from registration.

Execution
I, the undersigned, have signed this Form ADV-W on behalf of, and with the authority of, the adviser withdrawing its
registration. The adviser and I both certify, under penalty of perjury under the laws of the United States of America, that
the information and statements made in this Form ADV-W, including exhibits and any other information submitted, are
true. I further certify that the adviser’s books and records will be preserved and available for inspection as required by law,
and that all information previously submitted on Form ADV is accurate and complete as of this date. I understand that if
any information contained in items 1D or IE of this Form ADV-W is different from the information contained on Form
ADV, the information on this Form ADV-W will replace the corresponding entry on the adviser’s Form ADV composite
available through IARD. Finally, I authorize any person having custody or possession of these books and records to make
them available to authorized regulatory representatives.

Signature:

_________________________________

Date:

__________________________

Printed Name:

_________________________________

Title:

__________________________

FORM ADV-W

Your Name: ______________________________

SEC File No.: ___________________

Schedule W1

Date: ___________________________________

CRD No.: ______________________

(Paper Version)
Certain items in Form ADV-W may require additional information on this Schedule W1. Use this Schedule W1 to report details for items listed
below. Report only new information or changes/updates to previously submitted information. Do not repeat previously submitted information.
SECTION 5

Other Investment Advisory Contract Assignments

Check here if you are completing this section:
Complete the following information for each person to whom you have assigned any advisory contract. You must complete a separate Schedule
W1 for each person to whom you have assigned an advisory contract.
Name and business address of the person to whom advisory contracts were assigned:
______________________________________________________________________________________________________
(name)
______________________________________________________________________________________________________
(number and street)
______________________________________________________________________________________________________
(city)
(state)
(country)
(zip+4/postal code)
______________________________________
(area code)
(telephone number)

If this address is a private residence, check this box:
SECTION 8
Persons With Custody or Possession of the Books and Records Kept at the Location Described Below.
Complete the following information for the person that has or will have custody or possession of the books and records kept at the location
described in this Section 8 of this Schedule. You must complete a separate Schedule W1 for each person that has or will have custody of any of
your books and records. If the person you list below has or will have custody of any of your books and records at any other location, you must
complete separate Schedule(s) W1 listing this person and each other location of your books and records.
______________________________________________________________________________________________________
(name)
______________________________________________________________________________________________________
(number and street)
______________________________________________________________________________________________________
(city)
(state)
(country)
(zip+4/postal code)
______________________________________
(area code)
(telephone number)

If this address is a private residence, check this box:
Location of the Books and Records of Which the Person Listed in this Schedule W1 Has Custody or Possession.
Complete the following information for the location where the books and records of which the person listed in this Section 8 of this Schedule
has or will have custody or possession. You must complete a separate Schedule W1 for each location at which your records are or will be kept.
If any other person has or will have custody or possession of any of the books and records at the location described below, you must complete
separate Schedule(s) W1 listing this location and each other person that has or will have custody of your books and records.

____________________________________________________________________________________________
(name)
____________________________________________________________________________________________
(number and street)
____________________________________________________________________________________________
(city)
(state)
(country)
(zip+4/postal code)
___________________________________
(area code)
(telephone number)
If this address is a private residence, check this box:
Briefly describe the books and records kept at this location. ______________________________________________________________

FORM ADV-W

Your Name: ______________________________

SEC File No.: ___________________

Schedule W2

Date: ___________________________________

CRD No.: ______________________

(Paper Version)
If you answered “yes” to Items 3, 4, or 6 of Form ADV-W, you are required to complete this Schedule W2. This balance sheet must be prepared
in accordance with generally accepted accounting principles, but need not be audited.

I.

Assets
Current Assets
Cash

____________________________

Securities at Market

____________________________

Non-Marketable Securities

____________________________

Other Current Assets

____________________________

Total Current Assets

$___________________________

Fixed Assets
Total Fixed Assets

TOTAL ASSETS

$___________________________

$

LIABILITIES & SHAREHOLDERS’ EQUITY
Current Liabilities
Prepaid Advisory Fees

____________________________

Short-Term Loans from Clients

____________________________

Other Short-Term Loans

____________________________

Other Current Liabilities

____________________________

Total Current Liabilities

$___________________________

Fixed Liabilities
Long-Term Debt Owed to Clients

____________________________

Other Long-Term Debt

____________________________

Other Long-Term Liabilities

____________________________

Total Fixed Liabilities

$___________________________

Shareholders’ Equity
Total Shareholders’ Equity (or Deficit)
TOTAL LIABILITIES AND SHAREHOLDERS’ EQUITY

$___________________________

$