AFFIDAVIT OF INVESTMENT ADVISORY ACTIVITY IN NEBRASKA __________________________________________ (Name of Applicant) Applicant does hereby certify: ___ 1. That the above-named Applicant, by or through any of its investment advisor representatives or related persons, has not given investment advice for compensation to any Nebraska residents; That the above-named Applicant, by or through any of its investment advisor representatives or related persons, has engaged in the giving of investment advice for compensation to Nebraska residents, and all pertinent information relating to said advice is attached to this affidavit, including names and addresses of clients receiving investment advice, the dates such advisory services were provided as to each client, the nature of such investment advice as to each client, and the amount of fees generated from each client. ___ 2. 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) __________________________________________ (Printed Name) __________________________________________ (Title) Subscribed and sworn to before me this _____ day of _______________________, _________. __________________________________________ (Notary Public) My commission expires ___________________________________, __________. Revised 7/2014 American LegalNet, Inc. www.FormsWorkFlow.com