Form Adv-W - Notice Of Withdrawal From Registration As An Investment Adviser Page 4
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9FORM 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
DC
IA
MN
NM
PR
VI
AK
FL
KS
MS
NY
RI
VA
AZ
GA
KY
MO
NC
SC
WA
AR
GU
LA
MT
ND
SD
WV
CA
HI
ME
NE
OH
TN
WI
CO
ID
MD
NV
OK
TX
CT
IL
MA
NH
OR
UT
DE
IN
MI
NJ
PA
VT
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.
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