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 American LegalNet, Inc. www.FormsWorkFlow.com