Form Adv-H - Application For A Temporary Or Continuing Hardship Exemption

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Form ADV-H
APPLICATION FOR A TEMPORARY OR CONTINUING HARDSHIP EXEMPTION
Item 1
Type of Exemption
You are (check one):
Requesting a Temporary Hardship Exemption; or
Applying for a Continuing Hardship Exemption
A. If you are requesting a temporary hardship exemption, this Form ADV-H is for your (check one)
Initial SEC Application
Annual updating amendment to SEC Registration
Other-than-annual amendment to SEC Registration
Initial report to the SEC as an exempt reporting adviser
Annual updating amendment to your report as an exempt reporting adviser
Submit an other-than-annual amendment to your report as an exempt reporting adviser
Submit a final report an exempt reporting adviser
B. If you are applying for a continuing hardship exemption, this Form ADV-H is for all filings between the date you
file this form and ______________________________________ .
MM / DD / YYYY
Only an adviser that is a “small business” (as defined by SEC rule 0-7) is eligible for a continuing hardship
exemption. To determine whether you are eligible for a continuing hardship exemption, review Item 12 of the
Form ADV that you filed most recently with the SEC to answer the following questions:
Were you required to answer Item 12 of Part 1A of Form ADV?
Yes
No
Did you check “yes” to any question on Item 12 of Part 1A of Form ADV?
Yes
No
If you were not required to answer Item 12 or checked “yes” to any question on Item 12, you are not eligible for a
continuing hardship exemption and must submit electronic filings to the IARD system.
Item 2
Identifying Information
SEC File number:
801 - _____________
or
802 - ____________
CRD Number (if you have one) __________
A. Your full legal name (if you are a sole proprietor, state your last, first, and middle names):
______________________________________________________________________________
B. Principal Office and Place of Business
Address (do not use a P.O. Box):
______________________________________________________________________________
(number and street)
______________________________________________________________________________
(city)
(state)
(country)
(zip+4/postal code)
If this address is a private residence, check this box:
C. Name and telephone number of the individual filing this Form ADV-H:
__________________________________________________________________________________________
(name)
(title)
(area code)
(telephone number)
Item 3
Information Relating to the Hardship
A. If you are filing to request a temporary hardship exemption, attach a separate page that:
SEC 2566 (09-11)

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