AFFIDAVIT OF INVESTMENT ADVISORY ACTIVITY IN NEBRASKA
__________________________________________
(Name of Applicant)
Applicant does hereby certify:
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1.
That the above-named Applicant has not given investment advice for compensation to any
Nebraska residents;
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2.
That the above-named Applicant has engaged in the giving of investment advice for
compensation to Nebraska residents, and all pertinent information relating to said advice is
attached to this affidavit, including names and addresses of clients receiving investment
advice, the dates such advisory services were provided as to each client, the nature of such
investment advice as to each client, and the amount of fees generated from each client.
I, on behalf of _______________________________________________, acknowledge the foregoing to
(Name of Applicant)
be truthful with full knowledge that misrepresentation of such facts to the Department of Banking and
Finance of the State of Nebraska may result in administrative action by the Department.
__________________________________________
(Signature of Officer, Partner or Sole Proprietor)
__________________________________________
(Printed Name)
__________________________________________
(Title)
Subscribed and sworn to before me this _____ day of _______________________, _________.
__________________________________________
(Notary Public)
My commission expires ___________________________________, __________.
Revised 10/2011