STATE OF CALIFORNIA DEPARTMENT OF CORPORATIONS CUSTOMER AUTHORIZATION OF DISCLOSURE OF FINANCIAL RECORDS Pursuant to Corporations Code Section 25241 and Government Code Sections 7470 and 7473, any financial institution, wherever situated, possessing financial records of Name of (check appropriate designation(s) below) _________ Broker-Dealer _________ Investment Adviser is hereby authorized to disclose to the California Department of Corporations records of the above-named broker-dealer or investment adviser business whether such records relate to accounts which have been closed, accounts which are currently maintained, or accounts which are hereafter established. This authorization is effective as of the date of execution and shall remain effective until five years after the expiration or revocation of the above-named broker-dealer or investment adviser license, including renewals of such license. This authorization may not be revoked. The terms used in this authorization shall have the definitions contained in the California Right to Financial Privacy Act (Government Code Section 7460 et seq.) and the Corporate Securities Law (Corporations Code Section 25000 et seq.). The above-named licensee has duly caused this authorization to be signed on its behalf by the undersigned, thereunto duly authorized. Executed on _______________________, 20______ at _______________________________________ _____________________________ Licensee’s Department of Corporations File Number _______________________________________ Name of Licensee By ______________________________________ ______________________________________ (Title) QR 500.261 (1/00) 2001 © American LegalNet, Inc. STATE OF CALIFORNIA DEPARTMENT OF CORPORATIONS INSTRUCTIONS FOR CUSTOMER AUTHORIZATION OF DISCLOSURE OF FINANCIAL RECORDS On the reverse is a Customer Authorization of Disclosure of Financial Records form. The Commissioner of Corporations is authorized to require such authorization from certain licensees and other persons pursuant to the authority cited in the first paragraph of the form. The form must be properly executed and submitted with the attached application for license, qualification, registration or other authority. All information required on the form, except the signature of the person executing the form, is to be typewritten. If the form requests a Department of Corporations file number, the applicant need only provide such number if it is known to the applicant and is the type of file number appropriate for the license, qualification, registration or other authority applied for in the attached application. If additional authorization forms are needed, they may be obtained from any office of the Department of Corporations, or accurate copies of the form may be utilized by applicants. ADM 500.270 (07/90) 2001 © American LegalNet, Inc.