State of Washington
INVESTMENT ADVISER
Department of Financial Institutions
FISCAL YEAR END REPORT
Securities Division
(Due within 90 days of the end of fiscal year)
P.O. Box 9033
Olympia, WA 98507-9033
Item 1. Investment Adviser
Firm Name ____________________________________________
IARD No.
______________________
This report is for the
State of adviser’s principal
fiscal year ended:
____________________
place of business:
_______________________
Item 2. Form ADV
Note: You are required to review Part 1 of your Form ADV and file an annual updating amendment within 90
days of the end of your fiscal year. In addition, you are required to draft a new Form ADV Part 2 and upload it
to IARD.
Date last annual updating amendment to Part 1 of Form ADV was filed on IARD:
______________________
Date Form ADV Part 2 was filed on IARD:
______________________
Item 3. Financial Report
Balance sheet: Attach a copy of the investment adviser’s balance sheet dated as of the end of its most recent
fiscal year to this form. An interim financial statement will not satisfy this requirement. The balance sheet must
be prepared in accordance with generally accepted accounting principles.
Is the investment adviser able to meet its obligations and pay its debts as they come due in
Yes
No
the ordinary course of business?
For an investment adviser whose principal place of business is in Washington:
Note: If the investment adviser has discretion, the balance sheet must show a net worth of at least $10,000, and
if the investment adviser has custody of client funds or securities, it must show a net worth of at least $35,000
absent an exception. If the adviser is unable to satisfy these requirements, a surety bond must be obtained.
Does the firm have discretionary authority over client funds or securities?
Yes
No
Does the firm have custody of client funds or securities?
Yes
No
Does the firm have a surety bond in place?
Yes
No
If so, what is the amount of the bond?
________________
If not, does the firm have a subordination agreement in place?
Yes
No
For an investment adviser whose principal place of business is outside of Washington:
Is the investment adviser in compliance with any net worth or capital requirements
Yes
No
imposed by the state of its principal place of business?
Item 4. Certification
In submitting this report, I certify that I am a principal of the adviser and the information provided in this report
is true and complete to the best of my knowledge.
Name:
___________________________________________ Date:
________________
Title:
___________________________________________ Phone number:
________________
Revised 02/08/2011
1
