VERMONT SECURITIES DIVISION Firm Name: CRD #: TAX CERTIFICATION FOR BROKER-DEALER FIRM The Vermont Legislature has passed a law which provides that a professional license, including registration as a broker-dealer, may not be issued or renewed unless the broker-dealer certifies that it is in good standing with the Vermont Department of Taxes. A Good standing@ means that no taxes are due, the tax liability is on appeal, the taxpayer is in compliance with the payment plan approved by the Commissioner of Taxes, or the licensing authority determines that immediate payment of taxes would impose an unreasonable hardship (32 V.S.A. Section 3113). The maximum penalty for perjury is fifteen years in prison, a $10,000 fine, or both. ******************************************************************************** I hereby certify, under the pains and penalties of perjury, that this firm is in good standing with respect to or in full compliance with a plan to pay any and all taxes due the State of Vermont as of the date of this application. I further certify that all information contained in the application is true and accurate to the best of my knowledge. Date: Signature: Title: Type/Print Name: Business Address: ************************************************************************************************** THIS FORM IS TO BE USED FOR FIRM ONLY - NOT INDIVIDUAL SALES REPRESENTATIVES. PLEASE NOTE: IF YOU ARE NOT PRESENTLY IN GOOD STANDING WITH THE VERMONT DEPARTMENT OF TAXES, YOU MUST CONTACT THE COMPLIANCE DIVISION, COLLECTIONS AT 802-828-2518 TO MAKE ARRANGEMENTS TO OBTAIN TAX CLEARANCE FROM THAT DEPARTMENT. On-line Form 03/02 American LegalNet, Inc. www.USCourtForms.com