Department of Financial Regulation SECURITIES DIVISION AFFIDAVIT OF BROKERDEALER ACTIVITY WITHIN OR FROM VERMONT I _______________________ a principal of _____________________________ being duly authorized to represent the Applicant, have thoroughly and diligently searched and conducted a review of the Applicant's applicable books and records. The result of this review shows thatplease check one: o That since the date, if any, the Applicant was last duly registered as a BrokerDealer in Vermont, by or through any of its agents, has not offered for sale or sold any securities, solicited clients, maintained accounts, or been involved in any wrapfee programs within the State of Vermont. OR o That, since the date, if any, the Applicant was last duly registered as a BrokerDealer in Vermont, by or through any of its agents, has offered for sale or sold any securities, solicited clients, maintained accounts, or been involved in any wrapfee programs within the State of Vermont. The activity has been conducted with _________ (number of clients,) from __________ (start date) to ____________ (end date.) Attached is a list of all activity conducted within or from Vermont by the Applicant, by or through any of its agents. The list includes: a.) Name of address of each client within or from Vermont b.) Name, home address, business address, home telephone number, business telephone number, and Central Registration Depository or Social Security Number of each brokerdealer representative of the Applicant that serviced each client identified in Item (a) above. c.) Commission run for each client account identified in Item (a) above. American LegalNet, Inc. www.FormsWorkFlow.com If the Applicant and its brokerdealer representatives relied upon an exemption from registration, or believe to be exempt from the Vermont Uniform Securities Act, using a separate page, identify, in writing, the exemption relied upon or explain why the Applicant and its representatives were not subject to the registration requirements of the Vermont Uniform Securities Act. I, _______________________________(name of Principal,) acknowledge the foregoing to be truthful with the full knowledge that misrepresentations or omissions of such facts to the Commissioner of the Department of Financial Regulation of the State of Vermont may result in enforcement action by the Securities Division. _______________________________ Signature of Principal ________________ Date Subscribed and sworn to me this _____________ day of _____________, 20______ Notary Public ______________________________ My Commission Expires: _____________________ Notary's Seal Here Revised 4/16/2012 American LegalNet, Inc. www.FormsWorkFlow.com