DEPARTMENT OF BANKING AND FINANCE BUREAU OF SECURITIES COMMERCE COURT 1230 O STREET, SUITE 400 LINCOLN, NEBRASKA 68508 (402) 471-3445 AFFIDAVIT OF BROKER DEALER ACTIVITY IN NEBRASKA __________________________________________ (Name of Applicant) Applicant does hereby certify: ____ 1. that the above-named Applicant by or through any of its agents has not sold or entered into any agreements to sell any securities to any Nebraska residents, and that the Applicant and any of its agents will not engage in the securities business in Nebraska until registered. ____ 2. that the above-named Applicant by or through any of its agents has sold or entered into agreements to sell securities in Nebraska, and all pertinent information relating to said sales or agreements is attached to this affidavit, including names and addresses of customers, transaction dates, description of said transactions, and the amount of commissions generated from each customer. I, on behalf of _______________________________________________, acknowledge the foregoing to (Name of Applicant) be truthful with full knowledge that misrepresentation of such facts to the Department of Banking and Finance of the State of Nebraska may result in administrative action by the Department. __________________________________________ (Signature of Officer, Partner or Sole Proprietor) Subscribed and sworn to before me this ____ day of _______________________, _________. __________________________________________ (Notary Public) My commission expires ___________________________________, __________. Revised 4/2010 American LegalNet, Inc. www.FormsWorkFlow.com