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Customer Authorization Of Disclosure Of Financial Records QR 500.261 - California

Customer Authorization Of Disclosure Of Financial Records Form. This is a California form and can be used in Broker Dealer Blue Sky Secretary Of State .
 Fillable pdf Last Modified 3/13/2014
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STATE OF CALIFORNIA ­ DEPARTMENT OF BUSINESS OVERSIGHT Mail to: State of California Department of Business Oversight 1515 K Street, Suite 200 Sacramento, CA 95814-4052 DBO­260.211.1 (Rev. 11-13) APPLICATION BY NOTIFICATION FOR BROKER DEALER CERTIFICATE Fee: $300 File No. ____________________________ Date of Application ___________________ PURSUANT TO CORPORATIONS CODE SEC. 25211(b) (Only for Use in Connection with Applications and Amendments to Applications for Broker-Dealer Certificate Pursuant to Section 25211(b), Corporations Code (Application by Notification), and Section 260.241.4, Title 10, California Code of Regulations.) 1. 2. 3. Date of Notice: ________________________________________________________________ Original Notice Amended Notice Name of Broker-Dealer Address of Principal Office _____________________________________________________________________________ Name and address of officer or partner of the broker-dealer who is to receive compliance and information communications from the Department and who is responsible for disseminating the same within the broker-dealer's organization. Name ____________________________ Address __________________________ __________________________________ (See Corporations Code Section 25245) Title ___________________________ Telephone ( ) __________________ 4. 5. The following representations are made to the Commissioner of Business Oversight by the brokerdealer: a. The broker-dealer has a currently effective registration as a broker-dealer under the Securities Exchange Act of 1934 (15 USC 78a et seq.). The broker-dealer is a member in good standing of the self-regulatory organizations checked: NYSE NYSE AMEX NYSE Arca FINRA Check the applicable box: (1) The broker-dealer has never had a certificate as a broker-dealer, investment adviser or agent revoked, or an application for such a certificate denied, under the Corporate Securities Law of 1968 or any predecessor statute. The Commissioner has by order waived the denial or revocation of a certificate as a broker-dealer, investment adviser or agent heretofore issued to the broker-dealer. b. c. (2) 6. Exhibits. Attach the following exhibits: a. A completed Customer Authorization of Disclosure of Financial Records (Form QR 500.261) in subdivision (i) of Section 260.231. 1 American LegalNet, Inc. www.FormsWorkFlow.com FORM 260.211.1 (Rev. 11/13) STATE OF CALIFORNIA ­ DEPARTMENT OF BUSINESS OVERSIGHT DBO­260.211.1 (Rev. 11-13) b. APPLICATIONB BY NOTIFICATION FOR BROKER DEALER CERTIFICATE A completed Form BD (Uniform Application for Broker-Dealer Registration, 17 C.F.R. § 249.501) and the schedules thereto. NOTE: Social Security Numbers: In accordance with Section 7 of the Privacy Act of 1974 (PL. 93-579), the following information is provided in connection with the disclosure of social security account numbers in Form BD (Uniform Application for Broker-Dealer Registration, 17 C.F.R. § 249.501) and the Schedules thereto. Disclosure of a social security account number shall be considered a voluntary disclosure, except as provided below. A social security account number or federal taxpayer identification number under Business and Professions Code Section 494.5, is solicited pursuant to one or more of the following authorities: Section 25211, Corporations Code. Section 260.211, Title 10, California Code of Regulations. Section 17520, Family Code. Section 494.5, Business and Professions Code. Uses to be made of social security account numbers and federal taxpayer identification numbers, solicited by Form BD and the Schedules thereto are: A. For all persons disclosing social security account numbers, the number may be used, in addition to other information provided, to conduct a background investigation of the individual by the Department of Justice's Identification and Information Branch or by other federal, state or local law enforcement agencies. The social security number may also be used to respond to requests for this information made by child support agencies. Under Business and Professions Code Section 494.5, the social security number or federal taxpayer identification number is used to match the information to the names on the lists of tax delinquencies provided by the State Board of Equalization and the Franchise Tax Board. B. The completed form, except any disclosed social security account numbers and federal taxpayer identification numbers, shall become a public record and available to members of the public pursuant to the provisions of the Public Records Act (Government Code Sections 6250, et seq.). The State Board of Equalization and the Franchise Tax Board are authorized to share taxpayer information with the Department of Business Oversight, and in the event the state tax obligation is not paid by a certificate holder after a certificate is issued, the Department of Business Oversight may be required to suspend the certificate (Business and Professions Code Sections 31 and 494.5). 7. 8. 9. Applicant's Minimum Net Capital Requirement: $_____________ Applicant's Fiscal Year Ends: Execution: ____________________________ By ___________________________ ____________________________ (Title) / (Month/Day) FORM 260.211.1 (Rev. 11/13) 2 American LegalNet, Inc. www.FormsWorkFlow.com
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