FIS 0523 (11/07) Office of Financial and Insurance Services DUE ANNUALLY on or before December 31st of the current year Non-NASD Broker-Dealer Renewal Name of Broker-Dealer Your Michigan Broker-Dealer number: Address (This is NOT your CRD number) Contact person name and title NON- Contact person phone number City State Check if your address has changed since your last renewal Zip Code Tax ID number (FEIN) Contact person email address Does Broker-Dealer maintain a Michigan branch office? Yes No If yes, please attach a list of Michigan branch office locations. Agent listing List each agent of this broker-dealer. You may enter the agent information below, or provide an attachment with the same information in the same order as the format below: 1 Name of agent 3 Home address (must be street address--no PO Boxes) City Name of agent Home address (must be street address--no PO Boxes) State Zip Code City State Agent Social Security Number 2 State 4 Home address (must be street address--no PO Boxes) Name of agent Home address (must be street address--no PO Boxes) State Zip Code City Agent Social Security Number Agent Social Security Number Renewal Fee Calculation—Each Non-NASD Broker-Dealer firm is subject to a $300 renewal fee PLUS a $65 per agent renewal fee. Complete table below. Quantity Broker-Dealer Renewal Zip Code Agent Social Security Number Name of agent City Zip Code Amount Due 1 Mail completed form and any attachments with payment to: $300.00 OFIS-Securities Section 611 W Ottawa St PO Box 30701 Lansing MI 48909-8201 Agent Renewal (quantity x $65.00) TOTAL—Make check for full amount due payable in US dollars to: State of Michigan C3 Validation code: 8 Certification I swear under penalty of perjury that the information given in and attached to this application is true, complete and correct. I understand that Michigan requires broker-dealer audited financial statements to be submitted within 90 days from the end of the firm's fiscal year, and another unaudited financial statement with net capital computation as of a date six months after the audited statement. Signature of officer, member or owner Date signed Signer's name and title (typed or printed) Authority: PA 265 of 1964 as amended. Failure to properly file will result in expiration of your registration. Michigan Department of Labor & Economic Growth Visit OFIS online at: www.michigan.gov/ofis Phone OFIS toll-free at: 1-877-999-6442 The Department of Labor & Economic Growth will not discriminate against any individual or group because of race, sex, sexual orientation, religion, age, national origin, color, marital status, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency. American LegalNet, Inc. www.FormsWorkflow.com