SECURITIES DIVISION Vermont Department of Banking, Insurance, Securities & Health Care Administration Tel: 802-828-3420 TAX CERTIFICATION FOR INVESTMENT ADVISER FIRM (This form is to be used by a FIRM only – not individual investment adviser representatives.) Under Vermont law, a professional license -- including registration of an investment adviser -- may not be issued or renewed unless the registrant provides certification of good standing with the Vermont Department of Taxes. “Good standing” means that no taxes are due, 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. §3113). The maximum penalty for perjury is 15 years in prison, a $10,000 fine, or both. I hereby certify, under 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 or print name Address: ________________________________________________________ ________________________________________________________ ________________________________________________________ Phone: _________________________________________________ Please note: If you are presently not in good standing with the Vermont Tax Department, please contact the Compliance Division at 802-828-2821 to make arrangements to obtain tax clearance from that department. American LegalNet, Inc. www.USCourtForms.com