Fillable Form Dfi/dos/iafc(Wi)- Financial Certification (2012) printable pdf download

Form Dfi/dos/iafc(Wi)- Financial Certification (2012)

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§551.406(1)(b), Wis. Stats. and 5.01(2), Wis. Adm. Code

STATE OF WISCONSIN

DEPARTMENT OF FINANCIAL INSTITUTIONS

DIVISION OF SECURITIES

West Washington Ave. Suite 300

PO Box 1768

Madison, WI 53701-1768

You can fill out this form online by clicking on the Firm Name

(608) 266-2139

line, filling in the required information, and using the TAB key to

TTY: (608) 266-8818

advance to the next question. You must then print out the

Internet:

completed form for submission to the Division. Use the RESET

button at the bottom to clear all fields.

FINANCIAL CERTIFICATION

Pursuant to s. DFI-Sec 5.02, Wis. Adm. Code, every investment adviser whose principal office is located in

Wisconsin and that collects advisory fees of $1,200 or more, six months or more in advance shall maintain a positive

net worth at all times. If the investment adviser will have custody of client funds or securities, a $35,000 net capital

must be maintained. This shall be in the form of cash, securities or other liquid assets. If the investment adviser is

an individual, the capital used to meet the net capital requirement must be segregated from the individual’s personal

assets and used solely for the business for which the adviser is licensed.

FIRM’S NAME: _____________________________________________________________________________

FIRM’S ADDRESS:

_________________________________________________________________________

FIRM’S IARD NUMBER: ________________________

I, the undersigned, do hereby certify that the above mentioned firm has and will continue to maintain at all times, the

net capital sufficient to meet the requirement in s. DFI-Sec 5.02, Wis. Adm. Code.

I further certify that the accompanying financial statements are true to the best of my belief and knowledge.

___________________________________________________________________________________________

Typed Name and Title of an Officer of the Company

_________________________________________________________

_______________________________

Signature

Date

Reset Form

This document can be made available in alternate formats upon request to

qualifying individuals with disabilities.

DFI/DOS/IAFC(WI)(R11/12)

Form Dfi/dos/iafc(Wi)- Financial Certification (2012)

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