Form 133.13 - Application For Renewal Permit - 2012 Page 3
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3Form
133.13
STATE OF
COUNTY OF
The undersigned being duly sworn deposes and says that he or she has executed the foregoing
application for and on behalf of the applicant named therein; that he or she is
(title) of such applicant and is fully authorized to execute
and file such application; that he or she is familiar with such application; and to the best of his or
her knowledge, information, and belief the statements made in such application are true and the
documents submitted herewith are true copies of the originals thereof.
The undersigned further deposes and says that unless the State Securities Board has been notified
otherwise, no legal or administrative proceedings of a material nature have been instituted in which
the Issuer, its advisor, or any affiliate thereof was a party since publication of the Issuer’s most
recent prospectus.
(Signature)
(Capacity)
Subscribed and sworn to before me the
day of
, 20 _______
Notary Public in and for the County of
State of
(NOTARY SEAL)
My commission expires:
06-13-2012
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