Disciplinary Action Disclosure Statement printable pdf download

Disciplinary Action Disclosure Statement

DISCIPLINARY ACTION DISCLOSURE STATEMENT

(For Trustees and Key Employees only)

Please respond "yes" or "no" to the following questions:

________

Has any court in the United States or elsewhere ever

entered an order against you or found you to have been

involved in any illegal investment related activity?

________

In the past ten years, have you been convicted of or

pleaded guilty or no contest to a felony or misdemeanor

involving any investment related activities, fraud,

theft, bribery, forgery, counterfeiting or extortion?

________

In the past ten years, have you been convicted of or

pleaded guilty or no contest to any other felony?

________

Has any federal, state or foreign regulatory or self-

regulatory agency ever found you to be in violation of

its rules, to have made a false statement, or entered a

disciplinary order against you?

________

Have you ever had a professional license or

registration suspended, revoked or denied?

________

Has a bonding company ever denied, paid out on, or

revoked a bond as a result of any activities in which

you were involved?

________

Have you ever been an officer, director, or 10% or more

owner of a business which has been declared bankrupt,

made a compromise with creditors, or filed a petition

for bankruptcy?

________

To your knowledge, are you now the subject of any

investigation or proceeding that could result in a

"yes" answer to any of the above questions?

I agree to update this form promptly if any action

occurs in the future which would cause any of my

answers to these questions to change.

________________________________

___________________

Employee signature

Date

_________________________________

Printed name

TRS 540

ADOPTED 9/9/94 – Revised 9/24/04

Disciplinary Action Disclosure Statement

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