Department of Banking and Finance Bureau of Securities Commerce Court 1230 “O” Street, Suite 400 P.O. Box 95006 Lincoln, NE 68509-5006 (402) 471-3445 AFFIDAVIT OF INVESTMENT ADVISORY ACTIVITY IN NEBRASKA ____________________________________ Name of Applicant Applicant does hereby certify: _____ 1. that the above-named Applicant has not given investment advice for compensation to any Nebraska residents; _____ 2. that the above-named Applicant 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. I, on behalf of ____________________________________, acknowledge the foregoing (Name of Applicant) to 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 _______________, 200__. ____________________________________ (Notary Public) My commission expires ______________________, 200__. Revised 11/2004 American LegalNet, Inc. www.FormsWorkflow.com