Form SEC-2566 ADV-H

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Form ADV-H

APPLICATION FOR A TEMPORARY OR CONTINUING HARDSHIP EXEMPTION
Item 1

Type of Exemption

You are (check one):
□ Requesting a Temporary Hardship Exemption; or
□ Applying for a Continuing Hardship Exemption
A. If you are requesting a temporary hardship exemption, this Form ADV-H is for your (check one)
□ Initial SEC Application
□ Annual updating amendment to SEC Registration
□ Other-than-annual amendment to SEC Registration
 Initial report to the SEC as an exempt reporting adviser
 Annual updating amendment to your report as an exempt reporting adviser
 Submit an other-than-annual amendment to your report as an exempt reporting adviser
 Submit a final report an exempt reporting adviser
B. If you are applying for a continuing hardship exemption, this Form ADV-H is for all filings between the date you
file this form and ______________________________________ .
MM / DD / YYYY

Only an adviser that is a “small business” (as defined by SEC rule 0-7) is eligible for a continuing hardship
exemption. To determine whether you are eligible for a continuing hardship exemption, review Item 12 of the
Form ADV that you filed most recently with the SEC to answer the following questions:
Were you required to answer Item 12 of Part 1A of Form ADV?

Yes □ No □

Did you check “yes” to any question on Item 12 of Part 1A of Form ADV?
Yes □ No □
If you were not required to answer Item 12 or checked “yes” to any question on Item 12, you are not eligible for a
continuing hardship exemption and must submit electronic filings to the IARD system.

Item 2

Identifying Information

SEC File number:

801 - _____________

or

802 - ____________

CRD Number (if you have one) __________
A. Your full legal name (if you are a sole proprietor, state your last, first, and middle names):
______________________________________________________________________________
B. Principal Office and Place of Business
Address (do not use a P.O. Box):
______________________________________________________________________________
(number and street)
______________________________________________________________________________
(city)
(state)
(country)
(zip+4/postal code)
If this address is a private residence, check this box: □
C. Name and telephone number of the individual filing this Form ADV-H:
__________________________________________________________________________________________
(name)
(title)
(area code)
(telephone number)

Item 3

Information Relating to the Hardship

A. If you are filing to request a temporary hardship exemption, attach a separate page that:

SEC 2566 (09-11)

FORM ADV-H

PAGE 2

1.

Describes the nature and extent of the temporary technical difficulties when you attempt to submit the filing in
electronic format.

2.

Describes the extent to which you previously have submitted documents in electronic format with the same
hardware and software that you are unable to use to submit this filing.

3.

Describes the burden and expense of employing alternative means (e.g. public library, service provider) to
submit the filing in electronic format in a timely manner.

4.

Provides any other reasons why a temporary hardship exemption is warranted.

B. If you are applying for a continuing hardship exemption, your application will be granted or denied based on the
following items. You should attach a separate page to this Form ADV-H that:
1.

Explains the reason(s) that the necessary hardware and software are not available without unreasonable
burden and expense.

2.

Describes the burden and expense of employing alternative means (e.g. public library, service provider) to
submit your filings in electronic format in a timely manner.

3.

Justifies the time period requested in Item 1 of this Form ADV-H.

4.

Provides any other reasons why a continuing hardship exemption is warranted.

Item 4

How to Submit Your Form ADV-H

Sign this Form ADV-H. You must preserve in your records a copy of the Form ADV-H that you file. Mail one manually
signed Form ADV-H and one copy to U.S. Securities and Exchange Commission, Branch of Regulations and
Examinations, Mail Stop 0-25, 100 F Street, NE, Washington, DC 20549.

Item 5

Execution

I, the undersigned, have signed this Form ADV-H on behalf of, and with the authority of, the adviser requesting a
temporary hardship exemption or applying for a continuing hardship exemption. The undersigned and the adviser represent
that the information and statements made in this ADV-H, including any other information submitted, are true. The
undersigned and the adviser further agree to waive any claim against the administrator of the IARD for errors made in good
faith that may occur when converting to electronic format this Form ADV-H or any paper filing made in reliance of a
continuing hardship exemption.

Signature:

_________________________________

Date:

__________________________

Printed Name:

_________________________________

Title:

__________________________

PRIVACY ACT STATEMENT. Section 203(c)(1) of the Advisers Act [15 U.S.C. § 80b-3(c)(1)] authorizes the Commission to collect the information
required by Form ADV-H. The Commission collects this information for regulatory purposes, such as processing requests for temporary hardship
exemptions and determining whether to grant a continuing hardship exemption. Filing Form ADV-H is mandatory for investment advisers requesting a
temporary or continuing hardship exemption. The Commission maintains the information submitted on Form ADV-H and makes it publicly available.
The Commission may return forms that do not include required information. Intentional misstatements or omissions constitute federal criminal violations
under 18 U.S.C. § 1001 and 15 U.S.C. § 80b-17. The information contained in Form ADV-H is part of a system of records subject to the Privacy Act of
1974, as amended. The Commission has published in the Federal Register the Privacy Act System of Records Notice for these records.
SEC’S COLLECTION OF INFORMATION. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid control number. Section 203(c)(1) of the Advisers Act authorizes the Commission to collect the
information on this Form from applicants. See 15 U.S.C. § 80b-3(c)(1). Filing of this Form is mandatory for an investment adviser to request an
exemption from the electronic filing requirements. The principal purpose of this collection of information is to enable the Commission to process requests
for temporary hardship exemptions and to determine whether to grant a continuing hardship exemption. By accepting a form, however, the Commission
does not make a finding that it has been completed or submitted correctly. The Commission will maintain files of the information on Form ADV-H and

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will make the information publicly available. Any member of the public may direct to the Commission any comments concerning the accuracy of the
burden estimate on page one of Form ADV-H, and any suggestions for reducing this burden. This collection of information has been reviewed by the
Office of Management and Budget in accordance with the clearance requirements of 44 U.S.C. §3507.