Form ADV (Paper Version) Uniform Application For Investment Adviser Registration (Part 1B) (SEC1707) {ADV}

FORM ADV Part 1B Page 1 of 4 Your Name Date CRD Number SEC 801 or 802 Number FORM ADV (Paper Version) PART 1B UNIFORM APPLICATION FOR INVESTMENT ADVISER REGISTRATION You must complete this Part 1B only if you are applying for registration, or are registered, as an investment adviser with any of the state securities authorities. ITEM 1 STATE REGISTRATION Complete this Item 1 if you are submitting an initial application for state registration or requesting additional state registration(s). Check the boxes next to the states to which you are submitting this application. If you are already registered with at least one state and are applying for registration with an additional state or states, check the boxes next to the states in which you are applying for registration. Do not check the boxes next to the states in which you are currently registered or where you have an application for registration pending. AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA VI WA WV WI ITEM 2 Complete this item 2A. only if the person responsible for supervision and compliance does not appear in Item 1J. or 1K. of Form ADV Part 1A: ADDITIONAL INFORMATION A. Person responsible for supervision and compliance: (Name) (Title) (Area Code) (Telephone Number) (Number and Street) (City) Electronic mail (e-mail) address, if the person has one If this address is a private residence, check this box: (State/Country) (Zip+4/postal code) (Area Code) (Facsimile Number) B. Bond/Capital Information, if required by your home state. (1) Name of Issuing Insurance Company: (2) Amount of Bond: $ (3) Bond Policy Number: (4) If required by your home state, are you in compliance with your home state's minimum capital requirements? Revised 10/2012 .00 Yes No American LegalNet, Inc. www.FormsWorkFlow.com FORM ADV Part 1B Page 2 of 4 Your Name Date CRD Number SEC 801 or 802 Number For "yes" answers to the following question, complete a Bond DRP: C. Has a bonding company ever denied, paid out on, or revoked a bond for you, any advisory affiliate, or any management person? For "yes" answers to the following question, complete a Judgment/Lien DRP: D.Arethereanyunsatisfiedjudgmentsorliensagainstyou,anyadvisory affiliate, or any management person? Yes No For "yes" answers to the following questions, complete an Arbitration DRP: E. Are you, any advisory affiliate, or any management personcurrentlythesubjectof, or have you, any advisory affiliate,oranymanagementpersonbeenthesubjectof, an arbitration claim alleging damages in excess of $2,500, involving any of the following: (1) any investment or an investment-related business or activity? (2) fraud, false statement, or omission? (3) theft, embezzlement, or other wrongful taking of property? (4) bribery, forgery, counterfeiting, or extortion? (5) dishonest, unfair, or unethical practices? For "yes" answers to the following questions, complete a Civil Judicial Action DRP: F. Are you, any advisory affiliate, or any management personcurrentlysubjectto, or have you, any advisory affiliate, or any management person been found liable in, a civil, self-regulatory organization, or administrative proceeding involving any of the following: (1) an investment or investment-related business or activity? (2) fraud, false statement, or omission? (3) theft, embezzlement, or other wrongful taking of property? (4) bribery, forgery, counterfeiting, or extortion? (5) dishonest, unfair, or unethical practices? G. Other Business Activities (1) Are you, any advisory affiliate, or any management person actively engaged in business as a(n) (check all that apply): Tax Preparer Issuer of Securities Sponsor or syndicator of limited partnerships (or equivalent), excluding pooled investment vehicles Sponsor, general partner, managing member (or equivalent) of pooled investment vehicles Real estate adviser American LegalNet, Inc. www.FormsWorkFlow.com FORM ADV Part 1B Page 3 of 4 Your Name Date CRD Number SEC 801 or 802 Number (2) If you, any advisory affiliate, or any management person are actively engaged in any business other than those listed in Item 6.A. of Part 1 A or Item 2.G(1) of Part 1B, describe the business and the approximate amount of time spent on that business: H.Ifyouprovidefinancialplanningservices,theinvestmentsmadebasedonthoseservicesattheendofyourlast fiscalyeartotaled: Securities Non-Securities Investments Investments Under $100,000 $100,001 to $500,000 $500,001 to $1,000,000 $1,000,001 to $2,500,000 $2,500,001 to $5,000,000 More than $5,000,000 If securities investments are over $5,000,000, how much? $____________ (round to the nearest $1,000,000) If non-securities investments are over $5,000,000, how much? $____________ (round to the nearest $1,000,000) I. Custody (1) Advisory Fees Do you withdraw advisory fees directly from your clients' accounts? If you answered "yes", respond to the following: (a) Do you send a copy of your invoice to the custodian or trustee at the same time that you send a copy to the client? (b) Does the custodian send quarterly statements to your clients showing all disbursements for the custodian account, including the amount of the advisory fees? (c) Do your clients provide written authorization permitting you to be paid directly for their accounts held by the custodian or trustee? (2) Pooled Investment Vehicles and Trusts Yes No Yes No (a)(i) Do you or a related person act as general partner, managing member, or person serving in a similar capacity, for any pooled investment vehicle for which you are the adviser to the pooled investment vehicle, or for which you are the adviser to one or more of the investors in the pooled investment vehicle? If you answered "yes", respond to the following: (a)(ii) As the general partner, managing member, or person serving in a similar capacity, have you or a related person engaged any of the following to provide authority permitting each direct payment or any transfer of funds or securities from the account of the pooled investment vehicle? Attorney Independentcertifiedpublicaccountant Other independent party Describe the independent party: Yes No American LegalNet, Inc. www.FormsWorkFlow.com FORM ADV Part 1B Page 4 of 4 Your Name Date CRD Number SEC 801 or 802 Number For purposes of this Item 2I.2(a), "Independent party" means a person that: (A) is engaged by the investment adviser to act as a gatekeeper for the payment of fees, expe