Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Connecticut Supplement State-Registered Investment Advisers Form. This is a Connecticut form and can be use in Blue Sky Secretary Of State.
Loading PDF...
Tags: Connecticut Supplement State-Registered Investment Advisers, Connecticut Secretary Of State, Blue Sky
Connecticut Supplement
State-Registered Investment Advisers
Applicant Information
Applicant Name:
Exact Name of Applicant as Stated in Item 1 of Form ADV
IRS Number:
Applicant’s IRS Employer Identification Number
Pre-Existing Clients
The undersigned certifies, on behalf of the above Applicant, 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.
The undersigned certifies, on behalf of the above Applicant, that the Applicant (you may check more
than one box):
Has rendered investment advisory services to Connecticut residents
Is Connecticut-based and has rendered investment advisory services from Connecticut to
residents of one or more other jurisdictions
Attach a Separate Schedule Providing the Following:
•
•
•
•
•
•
•
Each client’s name and address
Specific dates the Applicant rendered investment 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
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 on which the
Applicant relied in providing investment advice to each client
A copy of the investment advisory contract, if any, with each client
Settlements With Other Regulatory Bodies
The undersigned certifies, on behalf of the above Applicant, 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 above Applicant, 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.
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.
American LegalNet, Inc.
www.FormsWorkflow.com
Pending Actions
The undersigned certifies, on behalf of the above Applicant, that the Applicant is not the subject of any
pending civil litigation or any securities-related 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 above Applicant, 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.
Undertakings Regarding Client Referrals; Unregistered Activity
The undersigned undertakes, on behalf of the above Applicant, that: 1) 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; and 2) the Applicant will not transact
business as an investment adviser in or from Connecticut until effectively registered as an investment
adviser in this state.
Workers’ Compensation Coverage
Section 31-286a(b) of the Connecticut General Statutes provides that "[o]n and after October 1, 1986,
no state department, board or agency may renew a license or permit to operate a business in this state
unless the applicant first presents sufficient evidence of current compliance with the workers’
compensation requirements of section 31-284."
Subsection (d) of Section 3l-286a states that "[f]or purposes of this section, ’sufficient evidence’ means
(1) a certificate of self-insurance issued by a workers’ compensation commissioner pursuant to Section
3l-284, or (2) a certificate of compliance issued by the insurance commissioner pursuant to Section 3l286, or (3) a certificate of insurance issued by any stock or mutual insurance company or mutual
association authorized to write workers’ compensation insurance in this state or its agent."
If you have questions about how Section 31-286a or Section 31-284 of the Connecticut General
Statutes applies to you, please direct them to your attorney or to the Workers’ Compensation
Commission at (860) 493-1500 rather than to the Department of Banking.
The Applicant represents as follows (only check one box):
The Applicant will not be operating a business in Connecticut within the meaning of Section 3l286a(b) of the Connecticut General Statutes and is not subject to Section 3l-284 of the Connecticut
General Statutes.
The Applicant will be operating a business in Connecticut within the meaning of Section 3l-286a(b)
of the Connecticut General Statutes and has attached a copy of the certificate required by that
section.
2
American LegalNet, Inc.
www.FormsWorkflow.com
Foreign Compliance Certification (Applicants Not Having a Connecticut Place of Business)
Check here if the Applicant does not have a Connecticut principal place of business and will not be
filing a Statement of Financial Condition with Connecticut.
The Applicant represents that: (1) The Applicant is licensed or registered as an investment adviser in
the state where it maintains its principal place of business; (2) the Applicant is, and will remain in
compliance with the net capital and/or bonding requirements of the state where it maintains its principal
place of business; (3) the Applicant is, and will remain in compliance with all applicable books and
records requirements of the state where it maintains its principal place of business; and (4) in the event
the Applicant should no longer be licensed or registered as an investment adviser in the state where it
maintains its principal place of business, the Applicant recognizes that it will become subject to
Connecticut capitalization requirements for investment advisers and to any supplementary books and
records requirements applicable to investment advisers having their principal place of business in this
state.
Signature
The undersigned, being duly sworn, does hereby certify, on behalf of the above 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
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
20
.
___________________________________________
Notary Public/Commissioner of the Superior Court
My Commission Expires:
Rev. 5/2008
3
American LegalNet, Inc.
www.FormsWorkflow.com