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