VERMONT DEPARTMENT OF BANKING, INSURANCE, SECURITIES AND HEALTH CARE ADMINISTRATION SECURITIES DIVISION CHILD SUPPORT CERTIFICATION AND TAX DECLARATION FOR BROKER-DEALER AGENTS AND INVESTMENT ADVISER REPRESENTATIVES Child Support Obligations. Vermont Law requires that a professional license, which includes registration as a BROKER-DEALER AGENT and registration as an INVESTMENT ADVISER REPRESENTATIVE, shall not be issued or renewed unless the licensed individual certifies that he or she is in good standing with respect to or in full compliance with a plan to pay any and all child support payable under a support order as of the date the application for licensure (original or renewal application) is filed. “Good standing” means that: (i) less than one-twelfth of the annual support obligation is overdue; (ii) liability for any support payable is being contested in a judicial or quasi-judicial proceeding; (iii) the person is in compliance with a repayment plan approved by the Office of Child Support or agreed to by the parties; or (iv) the licensing authority determines that immediate payment of support due and payable would impose an unreasonable hardship. (See 15 V.S.A. § 795) Vermont Tax Obligations. Vermont Law also requires that a professional license, which includes registration as a BROKER-DEALER AGENT and registration as an INVESTMENT ADVISER REPRESENTATIVE, shall not be issued or renewed unless the licensed individual declares, under pains and penalties of perjury, that he or she is in good standing with respect to any and all taxes payable under Vermont law. “Good standing” means that: (i) no Vermont state taxes are due and payable and all returns have been filed; (ii) the tax liability is on appeal; (iii) the taxpayer is in compliance with a payment plan approved by the Commissioner of Taxes; or (iv) the licensing authority determines that immediate payment of taxes would impose an unreasonable hardship. If the agency finds unreasonable hardship, it may condition renewal of registration on terms which will place the person in good standing as soon as reasonably possible. The maximum penalty for perjury is up to fifteen years in prison, a $10,000 fine, or both. (See 32 V.S.A. § 3113) I hereby certify that as of the date of this certification I am not subject to any child support order, or, if I am subject to a child support order, I am in good standing (as defined above) with respect thereto or in full compliance with a plan to pay any and all child support payable under each such support order. I hereby declare, under the pains and penalties of perjury, that I am in good standing (as defined above) with respect to or in full compliance with a plan to pay, any and all taxes due under Vermont law as of the date of this declaration. Date_______________ Name_________________________________________________ Social Security # _____________ Signature______________________________________________ Home Address_________________________________________________________________________ Name of Affiliated Investment Adviser or Broker-Dealer, as applicable: __________________________ _____________________________________________________________________________________ VT Office Address__________________________________________________ VT Phone__________ PLEASE NOTE: If you are not presently in good standing with the Vermont Department of Taxes you may contact them at 802-828-2518. If you are not presently in full compliance with a child support order or plan to pay child support, you may contact the Office of Child Support Services at 800-786-3214. This form may be duplicated as needed. Vermont Department of Banking, Insurance Securities and Health Care Administration, Securities Division 89 Main St., Montpelier, Vermont 05620-3101 Revised September 2007 American LegalNet, Inc. www.FormsWorkFlow.com