Form Adv-W - Notice Of Withdrawal From Registration As An Investment Adviser Page 10
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11FORM ADV-W
Your Name: ____________________________
SEC File No.: __________________
Schedule W1
Date: __________________________________
CRD No.: _____________________
(Pape r Ve rsion)
Certain items in Form ADV-W may require additional information on this Schedule W1. Use this Schedule W1 to report details for items
listed below. Report only new information or changes/updates to previously submitted information. Do not repeat previously submitted
information.
SECT ION 5
Other Investment Advisory Contract Assignments
Check here if you are completing this section:
[ ]
Complete the following information for each person to whom you have assigned any advisory contract. You must complete a separate
Schedule W1 for each person to whom you have assigned an advisory contract.
Name and business address of the person to whom advisory contracts were assigned:
_________________________________________________________________________________________________
(name)
_________________________________________________________________________________________________
(number and street)
_________________________________________________________________________________________________
(city)
(state)
(country)
(zip+4/postal code)
_____________________________________
(area code)
(telephone number)
If this address is a private residence, check this box:
[ ]
SECT ION 8
Persons With Custody or Possession of the Books and Records Kept at the Location Described Below.
Complete the following information for the person that has or will have custody or possession of the books and records kept at the location
described in this Section 8 of this Schedule. You must complete a separate Schedule W1 for each person that has or will have custody of any
of your books and records. If the person you list below has or will have custody of any of your books and records at any other location, you
must complete separate Schedule(s) W1 listing this person and each other location of your books and records.
_________________________________________________________________________________________________
(name)
_________________________________________________________________________________________________
(number and street)
_________________________________________________________________________________________________
(city)
(state)
(country)
(zip+4/postal code)
_____________________________________
(area code)
(telephone number)
If this address is a private residence, check this box:
[ ]
Location of the Books and Records of Which the Person Listed in this Schedule W1 Has Custody or Possession.
Complete the following information for the location where the books and records of which the person listed in this Section 8 of this Schedule
has or will have custody or possession. You must complete a separate Schedule W1 for each location at which your records are or will be
kept. If any other person has or will have custody or possession of any of the books and records at the location described below, you must
complete separate Schedule(s) W1 listing this location and each other person that has or will have custody of your books and records.
__________________________________________________________________________________
(name)
__________________________________________________________________________________
(number and street)
__________________________________________________________________________________
(city)
(state)
(country)
(zip+4/postal code)
_______________________________
(area code)
(telephone number)
If this address is a private residence, check this box:
[ ]
Briefly describe the books and records kept at this location. __________________________________________________________
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