Tax Certification For Investment Adviser Firm

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Vermont Securities Division
Department of Financial Regulation
89 Main Street, 2nd Floor
Montpelier, VT 05620-3101
802-828-3420 Fax: 802-828-2896
TAX CERTIFICATION FOR INVESTMENT ADVISER FIRM
This form is to be used by a FIRM only – not individual investment adviser representatives.
Under Vermont law, a professional license -- including registration of an investment adviser -- may
not be issued or renewed unless the registrant provides certification of good standing with the Vermont
Department of Taxes. “Good standing” means that no taxes are due, the taxpayer is in compliance
with the payment plan approved by the Commissioner of Taxes, or the licensing authority determines
that immediate payment of taxes would impose an unreasonable hardship (32 V.S.A. §3113).
The maximum penalty for perjury is 15 years in prison, a $10,000 fine, or both.
I hereby certify, under pains and penalties of perjury, that this firm is in good standing with respect
to, or in full compliance with a plan to pay any and all taxes due the State of Vermont as of the date of
this application. I further certify that all information contained in the application is true and accurate
to the best of my knowledge.
_________________________________
Date
______________________________________ / __________________________________________
Signature
Title
______________________________________
Type or print name
Address:
________________________________________________________
________________________________________________________
________________________________________________________
Phone: __________________________________________________
Please note: If you are presently not in good standing with the Vermont Tax Department, please
contact the Compliance Division at 802-828-2518 to make arrangements to obtain tax clearance
from that department.
Rev. 04/17/12

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