District Of Columbia Representative(S) Affidavit Form printable pdf download

District Of Columbia Representative(S) Affidavit Form

Government of the District of Columbia

Department of Insurance, Securities and Banking

DISTRICT OF COLUMBIA REPRESENTATIVE(S) AFFIDAVIT

Please be advised that I, __________________________________________________

(Principal/Officer’s name)

of the Investment Adviser _________________________________________________

(Adviser/Firm’s name)

on behalf of its applicant(s) ________________________________________________

(Representative (s) name)

certify that:

The applicant has not transacted any business in the District of

Columbia, and will not provide investment advice until registered

with the Securities Bureau of the District of Columbia.

If the applicant has effected transactions on behalf of District of

Columbia residents or within the District of Columbia while not

effectively licensed under the Act, please provide the following

information:

(a) name, address and telephone number of each client;

(b) date of each agreement with clients involved;

of assets managed or involved and the total amount of all fees received.

Signature _________________________________________________________

State of ____________________________

County of __________________________

Subscribed and sworn before me this ______ day of ________________, 20______.

________________________________

Notary Public

My Commission Expires _______________________

810 First Street, NE, Suite 701 •Washington, DC•20002•Tel: (202) 442-4934•Fax: (202) 442-8661

maurice.goff@dc.gov

District Of Columbia Representative(S) Affidavit Form