CONNECTICUT SUPPLEMENT FOR STATE-REGULATED INVESTMENT ADVISERS GENERAL 1. Exact Name of Applicant as Stated in Item 1 of Form ADV __________________________________ 2. Applicant's IRS Employer Identification Number: _______________________ CERTIFICATION CONCERNING PRE-EXISTING CLIENTS [ ] [ ] The undersigned certifies, on behalf of the aforementioned applicant for investment The undersigned certifies, on behalf of the aforementioned applicant for investment adviser registration, that the applicant has not rendered investment advisory services to any Connecticut resident, and, if the applicant is based in Connecticut, that the applicant has not rendered investment advisory services from Connecticut to residents of any other jurisdiction. adviser registration, that the applicant (you may check more than one box): [ ] Has rendered investment advisory services to Connecticut residents [ ] Is based in Connecticut and has rendered investment advisory services from Connecticut to residents of one or more other jurisdictions. Attach a Separate Schedule Providing the Following Information: * * * Each client’s name and address Specific dates the applicant rendered advisory services to each client For each client, the amount of investment advisory fees collected on a yearly basis from inception to the present How each client was introduced to the applicant The amount of any referral fees paid in connection with each account, the source of the referral fees and the recipient of the referral fees The exclusion or exemption, if any, under the Connecticut Uniform Securities Act upon which the applicant relied in providing investment advice to each client * * * Also Include a Copy of the Investment Advisory Contract, if any, with Each Client CERTIFICATION CONCERNING SETTLEMENTS WITH OTHER REGULATORY BODIES [ [ ] The undersigned certifies, on behalf of the aforementioned applicant for investment adviser registration, that the applicant has not entered into and is not now negotiating any consent order, agreement, stipulation, settlement or other contractual obligation with any state administrator for purposes of settling or otherwise disposing of allegations by the administrator of violation of, or lack of compliance with, any state securities law or order. ] The undersigned certifies, on behalf of the aforementioned applicant for investment adviser registration, that the applicant (you may check more than one box): [ ] Has entered into a consent order, agreement, stipulation, settlement or other contractual obligation with a state administrator for purposes of settling or otherwise disposing of allegations by the administrator of violation of, or lack of compliance with, any state securities law or order. American LegalNet, Inc. www.USCourtForms.com Connecticut Supplement Investment Adviser Registration Application Page 2 of 3 [ ] Is now negotiating a consent order, agreement, stipulation, settlement or other contractual obligation with a state administrator for purposes of settling or otherwise disposing of allegations by the administrator of violation of, or lack of compliance with, any state securities law or order. Attach a Separate Schedule Providing Details and Enclosing a Copy of all Final Agreements or Consent Orders CERTIFICATION CONCERNING PENDING ACTIONS [ ] The undersigned certifies, on behalf of the aforementioned applicant for investment adviser registration, that the applicant is not the subject of any pending civil litigation or any securitiesrelated complaints, actions or proceedings (whether civil, criminal, administrative or involving arbitration, including updates) which have not been reported on Form ADV and are otherwise reportable. [ ] The undersigned certifies, on behalf of the aforementioned applicant for investment adviser registration, that the applicant is the subject of pending civil litigation or a securities-related complaint, action or proceeding (whether civil, criminal, administrative or involving arbitration, including updates) which has not been reported on Form ADV and is otherwise reportable. Attach a Separate Schedule Providing Details and Enclosing a Copy of all Dispositional Documents UNDERTAKING CONCERNING COMPENSATION FOR CLIENT REFERRALS The undersigned undertakes, on behalf of the aforementioned applicant for investment adviser registration, that before directly or indirectly offering an individual additional compensation for client referrals, the applicant will ensure that such individual is registered as an investment adviser agent under the Connecticut Uniform Securities Act before the applicant pays compensation to such individual. UNDERTAKING NOT TO TRANSACT INVESTMENT ADVISORY BUSINESS ABSENT REGISTRATION The undersigned undertakes, on behalf of the aforementioned applicant for investment adviser registration, that the applicant will not transact business as an investment adviser in or from Connecticut until effectively registered as an investment adviser in this state. EXECUTION SECTION The undersigned, being duly sworn, does hereby certify, on behalf of the aforementioned applicant for investment adviser registration under the Connecticut Uniform Securities Act that he or she is authorized to execute this Connecticut Supplement on behalf of the applicant and that the information American LegalNet, Inc. www.USCourtForms.com Connecticut Supplement Investment Adviser Registration Application Page 3 of 3 contained herein, including any schedules and supplements included herewith, is complete, true and accurate. ______________________________________________________ Print Name of Signatory: ________________________________ Title: _________________________________________________ Subscribed and sworn to before me this ________ day of ____________ 200_____. ___________________________________________ Notary Public/Commissioner of the Superior Court My Commission Expires: Rev. 1/2001 American LegalNet, Inc. www.USCourtForms.com