"District of Columbia Representative(S) Affidavit Form" - Washington, D.C.

District of Columbia Representative(S) Affidavit Form is a legal document that was released by the Washington DC Department of Insurance, Securities and Banking - a government authority operating within Washington, D.C..

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Download "District of Columbia Representative(S) Affidavit Form" - Washington, D.C.

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Government of the District of Columbia
Department of Insurance, Securities and Banking
DISTRICT OF COLUMBIA REPRESENTATIVE(S) AFFIDAVIT
Please be advised that I, __________________________________________________
(Principal/Officer’s name)
of the Investment Adviser _________________________________________________
(Adviser/Firm’s name)
on behalf of its applicant(s) ________________________________________________
(Representative (s) name)
certify that:
The applicant has not transacted any business in the District of
Columbia, and will not provide investment advice until registered
with the Securities Bureau of the District of Columbia.
If the applicant has effected transactions on behalf of District of
Columbia residents or within the District of Columbia while not
effectively licensed under the Act, please provide the following
information:
(a) name, address and telephone number of each client;
(b) date of each agreement with clients involved;
(c) a description of services provided to each client along with the total amount
of assets managed or involved and the total amount of all fees received.
Signature _________________________________________________________
State of ____________________________
County of __________________________
Subscribed and sworn before me this ______ day of ________________, 20______.
________________________________
Notary Public
My Commission Expires _______________________
810 First Street, NE, Suite 701 •Washington, DC•20002•Tel: (202) 442-4934•Fax: (202) 442-8661
maurice.goff@dc.gov
Government of the District of Columbia
Department of Insurance, Securities and Banking
DISTRICT OF COLUMBIA REPRESENTATIVE(S) AFFIDAVIT
Please be advised that I, __________________________________________________
(Principal/Officer’s name)
of the Investment Adviser _________________________________________________
(Adviser/Firm’s name)
on behalf of its applicant(s) ________________________________________________
(Representative (s) name)
certify that:
The applicant has not transacted any business in the District of
Columbia, and will not provide investment advice until registered
with the Securities Bureau of the District of Columbia.
If the applicant has effected transactions on behalf of District of
Columbia residents or within the District of Columbia while not
effectively licensed under the Act, please provide the following
information:
(a) name, address and telephone number of each client;
(b) date of each agreement with clients involved;
(c) a description of services provided to each client along with the total amount
of assets managed or involved and the total amount of all fees received.
Signature _________________________________________________________
State of ____________________________
County of __________________________
Subscribed and sworn before me this ______ day of ________________, 20______.
________________________________
Notary Public
My Commission Expires _______________________
810 First Street, NE, Suite 701 •Washington, DC•20002•Tel: (202) 442-4934•Fax: (202) 442-8661
maurice.goff@dc.gov