Government of the District of Columbia Department of Insurance, Securities and Banking TRANSACTION CERTIFICATION ___________________________________ Broker-Dealer Name & CRD # _____________________ Date Please respond to one of the following, which pertains to transactions effected within the District of Columbia or with District of Columbia residents prior to registration under the District of Columbia Securities Act ("Act"). If your firm is claiming exemption from registration under the Act, please indicate the specific section pertaining to the exemption that your firm is claiming in the space below. ___________________________________________________________________________ ___________________________________________________________________________ No securities transactions have been effected on behalf of District of Columbia residents or within the District of Columbia while not effectively licensed under the Act. If your firm 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: 1) a list of all transactions including the names, addresses, and telephone numbers of clients involved in the transactions effected while not licensed in the District of Columbia; and order tickets and confirmations of any trades executed during the aforementioned time period. 2) _______________________________________ B/D Authorized Person & Date American LegalNet, Inc. www.FormsWorkFlow.com