VERMONT SECURITIES SALES REPRESENTATIVE CHILD SUPPORT AND TAX CERTIFICATION FORM Vermont Law requires that a professional license, including registration as a SECURITIES SALES REPRESENTATIVE, not be issued or renewed unless the registered salesperson 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 is filed. "Good standing" means that less than one-twelfth of the annual support obligation is overdue; or liability for any support payable is being contested in a judicial or quasi-judicial proceeding; or he or she is in compliance with a repayment plan approved by the office of child support or agreed to by the parties; or, the licensing authority determines that immediate payment of support would impose an unreasonable hardship (15 V.S.A. Section 795). In addition, a professional license or registration as a securities sales representative shall not be issued or renewed unless the registered securities sales representative certifies that he or she is in good standing with the Vermont Department of Taxes. "Good standing" means that no Vermont state taxes are due and payable and all returns have been filed, 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. If the agency finds unreasonable hardship, it may condition renewal on terms which will place the person in good standing as soon as reasonably possible (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 I am not subject to any child support order or that if I am subject to a child support order I am in compliance with such order as defined above, and I am 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. PLEASE PRINT OR TYPE: Signature __________________________________________________________ Date________________________ Name _____________________________________________ Social Security No. ___________________________ Home Address __________________________________________________________________________________ Name & CRD Number of Affiliated Broker-Dealer _____________________________________________________ VT Office Address _______________________________________________________________________________ VT Office Phone ____________________________________ PLEASE NOTE: IF YOU ARE NOT PRESENTLY IN GOOD STANDING WITH THE VERMONT DEPARTMENT OF TAXES, PLEASE CONTACT THEM AT 802-828-2821 TO MAKE ARRANGEMENTS TO OBTAIN TAX CLEARANCE FROM THAT DEPARTMENT. IF YOU ARE NOT PRESENTLY IN FULL COMPLIANCE WITH A PLAN TO PAY CHILD SUPPORT, YOU MAY CONTACT THE OFFICE OF CHILD SUPPORT SERVICES 1-800-786-3214. THIS FORM MAY BE DUPLICATED AS NEEDED. Securities Division, Vermont Department of Banking, Insurance, Securities & Health Care Administration 89 Main St. Drawer 20, Montpelier, VT 05620-3101 802-828-3420 American LegalNet, Inc. www.USCourtForms.com