Trade Or Assumed Name Notification {DBA-1}

SECURITIES INDUSTRY TRADE OR ASSUMED NAME NOTIFICATION (FORM DBA-1) INSTRUCTIONS WHO MUST FILE? The Connecticut Uniform Securities Act Regulations require that, before any Connecticut registered broker-dealer, investment adviser, agent or investment adviser agent (or any applicant for registration) may use a trade or assumed name, a notice on Form DBA-1 must be filed with the Securities and Business Investments Division. A Form DBA-1 must be filed even if the registrant or applicant uses both the trade name and the name already on file with the department in conducting its business. You must immediately report any material changes to Form DBA-1 to the department in writing. There is no fee for filing Form DBA-1 or amendments to the form. If your business is not securities-related, do not file this form. Instead, see C.G.S. §35-1 requiring that notice of a fictitious business name be filed with your local town clerk in Connecticut. SUBSTITUTIONS ALLOWED: Broker-dealer Applicants and Registrants: If you list all business names associated with your Connecticut activity on Section 1 of Schedule D of Form BD or Form BR, you may omit Form DBA-1. Investment Adviser Applicants and Registrants: If you list all business names associated with your Connecticut activity on Section 1.B of Schedule D of Form ADV or Form BR, you may omit Form DBA-1. Agents and Investment Adviser Agents: If your broker-dealer's or investment adviser's Connecticut branch office registration on Form BR provides information on your trade or assumed names, you may omit Form DBA-1. Otherwise, you should file Form DBA-1 since Form U-4 does not presently include information on trade or assumed names. COMPLETING FORM DBA-1 1. Trade or Assumed Name. Complete and file a Form DBA-1 for each trade or assumed name used in Connecticut. If the applicant or registrant will use more than one trade or assumed name, file a separate form for each name used. 2. Address of principal place of business. 3. Filing status. Only check one box. If you are amending Form DBA-1, please highlight the changes. 4. Identify the individual or entity using the trade or assumed name. If more than one individual or entity will use the name, complete a separate form for each user. 5. Provide the name and telephone number for the contact person filing this form. 6. Manually sign Form DBA-1 and return it to the Connecticut Securities and Business Investments Division. If you have questions about the form, please direct them to: State of Connecticut Department of Banking Securities and Business Investments Division 260 Constitution Plaza Hartford, CT 06103 Phone: (860) 240-8230 TRADE OR ASSUMED NAME NOTIFICATION (FORM DBA-1) 1 2. What is the trade or assumed name? __________________________________________ The principal place of business address for the person using the name is ___________________________________________________________________________ 3. Filing Status: ( ( ( ) ) ) Initial or first-time notice Amendment (highlight changes only) Termination notice (name no longer used) 4. The individual or entity using the Trade or Assumed Name is: ( ) A broker-dealer agent whose CRD number is ________________________ (if no CRD number, supply Social Security Number) and who is registered with the following broker-dealer in Connecticut: ________________________________________________ ( ) An investment adviser agent whose CRD number is___________________ (if no CRD number, supply Social Security Number) and who is registered with the following investment adviser in Connecticut: ____________________________________________ ( ( 5. 6. ) ) A broker-dealer whose CRD number is ___________________________________ An investment adviser whose CRD number is _______ _________(if applicable). Name of individual or entity using the Trade or Assumed Name: If the trade or assumed name will be used in connection with activity conducted on the premises of a financial institution, provide the institution's name: ___________________________________________________________________ 7. Who may we contact about this filing? (include phone number): ___________________________________________________________________ The undersigned certifies, under penalty of false statement, that the information provided herein and in any supplements included herewith is true, accurate and complete, and acknowledges that any material changes to such information must be immediately reported to the Securities and Business Investments Division of the State of Connecticut Department of Banking. __________________________________________ Signature and Date __________________________________________ Print name of person signing and provide title for business organizations other than proprietorships American LegalNet, Inc. www.FormsWorkFlow.com