SEC 1707 Form ADV Part1a

FORM ADV (Paper Version)
UNIFORM APPLICATION FOR INVESTMENT ADVISER REGISTRATION
AND
REPORT BY EXEMPT REPORTING ADVISERS
PART 1A
Complete this form truthfully. False statements or omissions may result in denial of your
application, revocation of your registration, or criminal prosecution. You must keep this form
updated by filing periodic amendments. See Form ADV General Instruction 4.

WARNING:

Check the box that indicates what you would like to do (check all that apply):
SEC or State Registration:
Submit an initial application to register as an investment adviser with the SEC.
Submit an initial application to register as an investment adviser with one or more states.
Submit an annual updating amendment to your registration for your fiscal year ended _________.
Submit an other-than-annual amendment to your registration.
SEC or State Report by Exempt Reporting Advisers:
Submit an initial report to the SEC.
Submit a report to one or more state securities authorities.
Submit an annual updating amendment to your report for your fiscal year ended _________.
Submit an other-than-annual amendment to your report.
Submit a final report.

Item 1

Identifying Information

Responses to this Item tell us who you are, where you are doing business, and how we can contact you.
A. Your full legal name (if you are a sole proprietor, your last, first, and middle names):
___________________________________________________________
B. Name under which you primarily conduct your advisory business, if different from Item 1.A.
_____________________________________________________________________________
List on Section 1.B. of Schedule D any additional names under which you conduct your advisory business.
C. If this filing is reporting a change in your legal name (Item 1.A.) or primary business name (Item 1.B.),
enter the new name and specify whether the name change is of  your legal name or  your primary
business name:
_____________________________________________________________________________
D. (1) If you are registered with the SEC as an investment adviser, your SEC file number: 801-___________
(2) If you report to the SEC as an exempt reporting adviser, your SEC file number: 802-___________
E. If you have a number (“CRD Number”) assigned by the FINRA’s CRD system or by the IARD system,
your CRD number: ___________

SEC 1707 (09-11)
File 2 of 4

FORM ADV
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Your Name_____________________
Date_____________________

CRD Number_____________________
SEC 801- or 802 Number_____________________

If your firm does not have a CRD number, skip this Item 1.E. Do not provide the CRD number of one of
your officers, employees, or affiliates.
F.

Principal Office and Place of Business
(1) 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:



List on Section 1.F. of Schedule D any office, other than your principal office and place of business, at
which you conduct investment advisory business. If you are applying for registration, or are registered,
with one or more state securities authorities, you must list all of your offices in the state or states to which
you are applying for registration or with whom you are registered. If you are applying for SEC
registration, if you are registered only with the SEC, or if you are reporting to the SEC as an exempt
reporting adviser, list the largest five offices in terms of numbers of employees.
(2) Days of week that you normally conduct business at your principal office and place of business:
 Monday - Friday  Other: _____________________________________________
Normal business hours at this location: _______________________________________
(3) Telephone number at this location: ___________________________________________
(area code)
(telephone number)
(4) Facsimile number at this location: ____________________________________________
(area code)
(facsimile number)
G. Mailing address, if different from your principal office and place of business address:
____________________________________________________________________
(number and street)
____________________________________________________________________
(city)
(state/country)
(zip+4/postal code)
If this address is a private residence, check this box:
H. If you are a sole proprietor, state your full residence address, if different from your principal office and
place of business address in Item 1.F.:
____________________________________________________________________
(number and street)
____________________________________________________________________
(city)
(state/country)
(zip+4/postal code)

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I.

Your Name_____________________
Date_____________________

Do you have one or more websites?

Yes

CRD Number_____________________
SEC 801- or 802 Number_____________________

No

If ”yes,” list all website addresses on Section 1.I. of Schedule D. If a website address serves as a portal
through which to access other information you have published on the web, you may list the portal without
listing addresses for all of the other information. Some advisers may need to list more than one portal
address. Do not provide individual electronic mail (e-mail) addresses in response to this Item.
J.

Provide the name and contact information of your Chief Compliance Officer: If you are an exempt
reporting adviser, you must provide the contact information for your Chief Compliance Officer, if you
have one. If not, you must complete Item 1.K. below.
___________________________________________________________________________
(name)
____________________________________________________________________________
(other titles, if any)
_____________________________________ ____________________________________
(area code) (telephone number)
(area code) (facsimile number)
____________________________________________________________________
(number and street)
____________________________________________________________________
(city)
(state/country)
(zip+4/postal code)
_________________________________________________
(electronic mail (e-mail) address, if Chief Compliance Officer has one)

K. Additional Regulatory Contact Person: If a person other than the Chief Compliance Officer is authorized
to receive information and respond to questions about this Form ADV, you may provide that information
here.
___________________________________________________________________________
(name)
____________________________________________________________________________
(titles)
____________________________________
____________________________________
(area code) (telephone number)
(area code) (facsimile number)
____________________________________________________________________
(number and street)
____________________________________________________________________
(city)
(state/country)
(zip+4/postal code)
_________________________________________________
(electronic mail (e-mail) address, if contact person has one)
L. Do you maintain some or all of the books and records you are required to keep under Section 204 of the
Advisers Act, or similar state law, somewhere other than your principal office and place of business?
Yes

No

If "yes,” complete Section 1.L. of Schedule D.

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Your Name_____________________
Date_____________________

CRD Number_____________________
SEC 801- or 802 Number_____________________

M. Are you registered with a foreign financial regulatory authority?

Yes

No

Answer “no” if you are not registered with a foreign financial regulatory authority, even if you have an
affiliate that is registered with a foreign financial regulatory authority. If "yes," complete Section 1.M. of
Schedule D.
N. Are you a public reporting company under Sections 12 or 15(d) of the Securities Exchange Act of 1934?
Yes

No

If “yes,” provide your CIK number (Central Index Key number that the SEC assigns to each public
reporting company): ______________________________
O. Did you have $1 billion or more in assets on the last day of your most recent fiscal year?
Yes

No

P. Provide your Legal Entity Identifier if you have one: __________________________________
A legal entity identifier is a unique number that companies use to identify each other in the financial
marketplace. In the first half of 2011, the legal entity identifier standard was still in development. You
may not have a legal entity identifier.

Item 2
SEC Registration
Responses to this Item help us (and you) determine whether you are eligible to register with the SEC. Complete this
Item 2.A. only if you are applying for SEC registration or submitting an annual updating amendment to your SEC
registration.
A. To register (or remain registered) with the SEC, you must check at least one of the Items 2.A.(1) through
2.A.(12), below. If you are submitting an annual updating amendment to your SEC registration and you
are no longer eligible to register with the SEC, check Item 2.A.(13). Part 1A Instruction 2 provides
information to help you determine whether you may affirmatively respond to each of these items.
You (the adviser):
(1) are a large advisory firm that either:
(a) has regulatory assets under management of $100 million (in U.S. dollars) or more, or
(b) has regulatory assets under management of $90 million (in U.S. dollars) or more at the time of
filing its most recent annual updating amendment and is registered with the SEC;
(2) are a mid-sized advisory firm that has regulatory assets under management of $25 million (in
U.S. dollars) or more but less than $100 million (in U.S. dollars) and you are either:
(a) not required to be registered as an adviser with the state securities authority of the state where
you maintain your principal office and place of business, or

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Your Name_____________________
Date_____________________

CRD Number_____________________
SEC 801- or 802 Number_____________________

(b) not subject to examination by the state securities authority of the state where you maintain
your principal office and place of business;
Click HERE for a list of states in which an investment adviser, if registered, would not be
subject to examination by the state securities authority.
(3) have your principal office and place of business in Wyoming (which does not regulate advisers);
(4) have your principal office and place of business outside the United States;
(5) are an investment adviser (or sub-adviser) to an investment company registered under the
Investment Company Act of 1940;
(6) are an investment adviser to a company which has elected to be a business development
company pursuant to section 54 of the Investment Company Act of 1940 and has not withdrawn
the election, and you have at least $25 million of regulatory assets under management;
(7) are a pension consultant with respect to assets of plans having an aggregate value of at least
$200,000,000 that qualifies for the exemption in rule 203A-2(a);
(8) are a related adviser under rule 203A-2(b) that controls, is controlled by, or is under common
control with, an investment adviser that is registered with the SEC, and your principal office and
place of business is the same as the registered adviser;
If you check this box, complete Section 2.A.(8) of Schedule D.
(9) are a newly formed adviser relying on rule 203A-2(c) because you expect to be eligible for SEC
registration within 120 days;
If you check this box, complete Section 2.A.(9) of Schedule D.
(10) are a multi-state adviser that is required to register in 15 or more states and is relying on rule
203A-2(d);
If you check this box, complete Section 2.A.(10) of Schedule D.
(11) are an Internet adviser relying on rule 203A-2(e);
(12) have received an SEC order exempting you from the prohibition against registration with the
SEC;
If you check this box, complete Section 2.A.(12) of Schedule D.
(13) are no longer eligible to remain registered with the SEC.

SEC Reporting by Exempt Reporting Advisers
B. Complete this Item 2.B. only if you are reporting to the SEC as an exempt reporting adviser. Check all that
apply. You:
(1) qualify for the exemption from registration as an adviser solely to one or more venture capital
funds;

FORM ADV
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Your Name_____________________
Date_____________________

CRD Number_____________________
SEC 801- or 802 Number_____________________

(2) qualify for the exemption from registration because you act solely as an adviser to private funds
and have assets under management in the United States of less than $150 million;
(3) act solely as an adviser to private funds but you are no longer eligible to check box 2.B.(2)
because you have assets under management in the United States of $150 million or more.
If you check box (2) or (3), complete Section 2.B. of Schedule D.

State Securities Authority Notice Filings and State Reporting by Exempt
Reporting Advisers
C. Under state laws, SEC-registered advisers may be required to provide to state securities authorities a copy
of the Form ADV and any amendments they file with the SEC. These are called notice filings. In addition,
exempt reporting advisers may be required to provide state securities authorities with a copy of reports and
any amendments they file with the SEC. If this is an initial application or report, check the box(es) next to
the state(s) that you would like to receive notice of this and all subsequent filings or reports you submit to
the SEC. If this is an amendment to direct your notice filings or reports to additional state(s), check the
box(es) next to the state(s) that you would like to receive notice of this and all subsequent filings or reports
you submit to the SEC. If this is an amendment to your registration to stop your notice filings or reports
from going to state(s) that currently receive them, uncheck the box(es) next to those state(s).
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

VI
VA
WA
WV
WI

If you are amending your registration to stop your notice filings or reports from going to a state that
currently receives them and you do not want to pay that state’s notice filing or report filing fee for the
coming year, your amendment must be filed before the end of the year (December 31).

Item 3

Form of Organization

A. How are you organized?
Corporation
Sole Proprietorship
Limited Liability Partnership (LLP)
Partnership
Limited Liability Company (LLC)
Limited Partnership (LP)
Other (specify):__________________________________________________________________
If you are changing your response to this Item, see Part 1A Instruction 4.
B. In what month does your fiscal year end each year? ___________________
C. Under the laws of what state or country are you organized? ______________________
If you are a partnership, provide the name of the state or country under whose laws your partnership was
formed. If you are a sole proprietor, provide the name of the state or country where you reside.
If you are changing your response to this Item, see Part 1A Instruction 4.

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Item 4

Your Name_____________________
Date_____________________

CRD Number_____________________
SEC 801- or 802 Number_____________________

Successions

A. Are you, at the time of this filing, succeeding to the business of a registered investment adviser?
Yes

No

If “yes,” complete Item 4.B. and Section 4 of Schedule D.
B. Date of Succession:

____________________
(mm/dd/yyyy)

If you have already reported this succession on a previous Form ADV filing, do not report the succession
again. Instead, check “No.” See Part 1A Instruction 4.

Item 5

Information About Your Advisory Business

Responses to this Item help us understand your business, assist us in preparing for on-site examinations, and provide
us with data we use when making regulatory policy. Part 1A Instruction 5.a. provides additional guidance to newly
formed advisers for completing this Item 5.

Employees
If you are organized as a sole proprietorship, include yourself as an employee in your responses to Item 5.A
and Items 5.B.(1), (2), (3), (4), and (5). If an employee performs more than one function, you should count that
employee in each of your responses to Items 5.B.(1), (2), (3), (4) and (5).
A. Approximately how many employees do you have? Include full- and part-time employees but do not
include any clerical workers.
_____________
B.

(1) Approximately how many of the employees reported in 5.A. perform investment advisory functions
(including research)?
_____________
(2) Approximately how many of the employees reported in 5.A. are registered representatives of a brokerdealer?
_____________
(3) Approximately how many of the employees reported in 5.A. are registered with one or more state
securities authorities as investment adviser representatives?
_____________
(4) Approximately how many of the employees reported in 5.A. are registered with one or more state
securities authorities as investment adviser representatives for an investment adviser other than you?
_____________
(5) Approximately how many of the employees reported in 5.A. are licensed agents of an insurance
company or agency?
_____________

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Your Name_____________________
Date_____________________

CRD Number_____________________
SEC 801- or 802 Number_____________________

(6) Approximately how many firms or other persons solicit advisory clients on your behalf?
_____________
In your response to Item 5.B.(6), do not count any of your employees and count a firm only once – do not
count each of the firm’s employees that solicit on your behalf.

Clients
In your responses to Items 5.C. and 5.D. do not include as “clients” the investors in a private fund you advise,
unless you have a separate advisory relationship with those investors.
C. (1) To approximately how many clients did you provide investment advisory services during your most
recently completed fiscal year?
0

1-10

11-25

26-100

If more than 100, how many? ______

(round to the nearest 100)

(2) Approximately what percentage of your clients are non-United States persons? ______%
D. For purposes of this Item 5.D., the category “individuals” includes trusts, estates, and 401(k) plans and
IRAs of individuals and their family members, but does not include businesses organized as sole
proprietorships.
The category “business development companies” consists of companies that have made an election
pursuant to section 54 of the Investment Company Act of 1940. Unless you provide advisory services
pursuant to an investment advisory contract to an investment company registered under the Investment
Company Act of 1940, check “None” in response to Item 5.D.(1)(d) and do not check any of the boxes in
response to Item 5.D.(2)(d).
(1) What types of clients do you have? Indicate the approximate percentage that each type of client
comprises of your total number of clients. If a client fits into more than one category, check all
that apply.
None
(a) Individuals (other than
high net worth individuals)
(b) High net worth individuals
(c) Banking or thrift institutions
(d) Investment companies
(e) Business development companies
(f) Pooled investment vehicles (other than
investment companies)
(g) Pension and profit sharing plans
(but not the plan participants)
(h) Charitable organizations
(i) Corporations or other businesses
not listed above
(j) State or municipal government entities
(k) Other investment advisers
(l) Insurance companies

Up to 11- 2610% 25% 50%

5175%

7699% 100%

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Your Name_____________________
Date_____________________

CRD Number_____________________
SEC 801- or 802 Number_____________________

(m) Other: ___________________________

(2) Indicate the approximate amount of your regulatory assets under management (reported in Item 5.F.
below) attributable to each of the following type of client. If a client fits into more than one category,
check all that apply.
None

Up to
25%

Up to
50%

Up to
75%

>75%

(a) Individuals (other than
high net worth individuals)
(b) High net worth individuals
(c) Banking or thrift institutions
(d) Investment companies
(e) Business development companies
(f) Pooled investment vehicles (other than
investment companies)
(g) Pension and profit sharing plans
(but not the plan participants)
(h) Charitable organizations
(i) Corporations or other businesses
not listed above
(j) State or municipal government entities
(k) Other investment advisers
(l) Insurance companies
(m) Other: ___________________________

Compensation Arrangements
E. You are compensated for your investment advisory services by (check all that apply):
(1)
(2)
(3)
(4)
(5)
(6)
(7)

A percentage of assets under your management
Hourly charges
Subscription fees (for a newsletter or periodical)
Fixed fees (other than subscription fees)
Commissions
Performance-based fees
Other (specify): __________________________________________________

Regulatory Assets Under Management
F.

(1) Do you provide continuous and regular supervisory or management services to securities
portfolios?
Yes
No
(2) If yes, what is the amount of your regulatory assets under management and total number of accounts?
U.S. Dollar Amount
Discretionary:

(a) $______________.00

Total Number of Accounts
(d) ______________

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Your Name_____________________
Date_____________________

Non-Discretionary:
Total:

CRD Number_____________________
SEC 801- or 802 Number_____________________

(b) $______________.00

(e) ______________

(c) $______________.00

(f) ______________

Part 1A Instruction 5.b. explains how to calculate your regulatory assets under management. You must
follow these instructions carefully when completing this Item.

Advisory Activities
G. What type(s) of advisory services do you provide? Check all that apply.
(1) Financial planning services
(2) Portfolio management for individuals and/or small businesses
(3) Portfolio management for investment companies (as well as “business development companies”
that have made an election pursuant to section 54 of the Investment Company Act of 1940)
(4) Portfolio management for pooled investment vehicles (other than investment companies)
(5) Portfolio management for businesses (other than small businesses) or institutional clients
(other than registered investment companies and other pooled investment vehicles)
(6) Pension consulting services
(7) Selection of other advisers (including private fund managers)
(8) Publication of periodicals or newsletters
(9) Security ratings or pricing services
(10) Market timing services
(11) Educational seminars/workshops
(12) Other (specify): _____________________________________________
Do not check Item 5.G.(3) unless you provide advisory services pursuant to an investment advisory contract to
an investment company registered under the Investment Company Act of 1940, including as a subadviser. If
you check Item 5.G.(3), report the 811 or 814 number of the investment company or investment companies to
which you provide advice in Section 5.G. of Schedule D.
H. If you provide financial planning services, to how many clients did you provide these services during your
last fiscal year?
0
1-10
More than 500

11-25
26-50
51-100
If more than 500, how many? ______

101-250
251 – 500
(round to the nearest 500)

In your responses to this Item 5.H., do not include as “clients” the investors in a private fund you advise, unless
you have a separate advisory relationship with those investors.
I.

If you participate in a wrap fee program, do you (check all that apply):
(1) sponsor the wrap fee program?
(2) act as a portfolio manager for the wrap fee program?
If you are a portfolio manager for a wrap fee program, list the names of the programs and their sponsors in
Section 5.I.(2) of Schedule D.
If your involvement in a wrap fee program is limited to recommending wrap fee programs to your clients,
or you advise a mutual fund that is offered through a wrap fee program, do not check either Item 5.I.(1) or
5.I(2).

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J.

Your Name_____________________
Date_____________________

CRD Number_____________________
SEC 801- or 802 Number_____________________

In response to Item 4.B. of Part 2A of Form ADV, do you indicate that you provide investment advice only
with respect to limited types of investments?
Yes
No

Item 6

Other Business Activities

In this Item, we request information about your firm’s other business activities.
A. You are actively engaged in business as a (check all that apply):
(1) broker-dealer (registered or unregistered)
(2) registered representative of a broker-dealer
(3) commodity pool operator or commodity trading advisor (whether registered or exempt from
registration)
(4) futures commission merchant
(5) real estate broker, dealer, or agent
(6) insurance broker or agent
(7) bank (including a separately identifiable department or division of a bank)
(8) trust company
(9) registered municipal advisor
(10) registered security-based swap dealer
(11) major security-based swap participant
(12) accountant or accounting firm
(13) lawyer or law firm
(14) other financial product salesperson (specify): _____________________________________
If you engage in other business using a name that is different from the names reported in Items 1.A. or 1.B,
complete Section 6.A. of Schedule D.
B. (1) Are you actively engaged in any other business not listed in Item 6.A. (other than giving investment
advice)?
Yes
No
(2) If yes, is this other business your primary business?

Yes

No

If “yes,” describe this other business on Section 6.B.(2) of Schedule D, and if you engage in this
business under a different name, provide that name.
(3) Do you sell products or provide services other than investment advice to your advisory clients?
Yes
No
If “yes,” describe this other business on Section 6.B.(3) of Schedule D, and if you engage in this
business under a different name, provide that name.

Item 7

Financial Industry Affiliations and Private Fund Reporting

In this Item, we request information about your financial industry affiliations and activities. This information
identifies areas in which conflicts of interest may occur between you and your clients.
A. This part of Item 7 requires you to provide information about you and your related persons, including
foreign affiliates. Your related persons are all of your advisory affiliates and any person that is under
common control with you.
You have a related person that is a (check all that apply):
(1) broker-dealer, municipal securities dealer, or government securities broker or dealer (registered

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Your Name_____________________
Date_____________________

CRD Number_____________________
SEC 801- or 802 Number_____________________

or unregistered)
other investment adviser (including financial planners)
registered municipal advisor
registered security-based swap dealer
major security-based swap participant
commodity pool operator or commodity trading advisor (whether registered or exempt from
registration)
(7) futures commission merchant
(8) banking or thrift institution
(9) trust company
(10) accountant or accounting firm
(11) lawyer or law firm
(12) insurance company or agency
(13) pension consultant
(14) real estate broker or dealer
(15) sponsor or syndicator of limited partnerships (or equivalent), excluding pooled
investment vehicles
(16) sponsor, general partner, managing member (or equivalent) of pooled investment vehicles
(2)
(3)
(4)
(5)
(6)

For each related person, including foreign affiliates that may not be registered or required to be registered
in the United States, complete Section 7.A. of Schedule D.
You do not need to complete Section 7.A. of Schedule D for any related person if: (1) you have no business
dealings with the related person in connection with advisory services you provide to your clients; (2) you
do not conduct shared operations with the related person; (3) you do not refer clients or business to the
related person, and the related person does not refer prospective clients or business to you; (4) you do not
share supervised persons or premises with the related person; and (5) you have no reason to believe that
your relationship with the related person otherwise creates a conflict of interest with your clients.
You must complete Section 7.A. of Schedule D for each related person acting as qualified custodian in
connection with advisory services you provide to your clients (other than any mutual fund transfer agent
pursuant to rule 206(4)-2(b)(1)), regardless of whether you have determined the related person to be
operationally independent under rule 206(4)-2 of the Advisers Act.
B. Are you an adviser to any private fund?

Yes

No

If “yes,” then for each private fund that you advise, you must complete a Section 7.B.(1) of Schedule D,
except in certain circumstances described in the next sentence and in Instruction 6 of the Instructions to
Part 1A. If another adviser reports this information with respect to any such private fund in Section 7.B.(1)
of Schedule D of its Form ADV (e.g., if you are a subadviser), do not complete Section 7.B.(1) of
Schedule D with respect to that private fund. You must, instead, complete Section 7.B.(2) of Schedule D.
In either case, if you seek to preserve the anonymity of a private fund client by maintaining its identity in
your books and records in numerical or alphabetical code, or similar designation, pursuant to rule 2042(d), you may identify the private fund in Section 7.B.(1) or 7.B.(2) of Schedule D using the same code or
designation in place of the fund’s name.

Item 8

Participation or Interest in Client Transactions

In this Item, we request information about your participation and interest in your clients’ transactions. This
information identifies additional areas in which conflicts of interest may occur between you and your clients.

FORM ADV
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Your Name_____________________
Date_____________________

CRD Number_____________________
SEC 801- or 802 Number_____________________

Like Item 7, Item 8 requires you to provide information about you and your related persons, including foreign
affiliates.
Proprietary Interest in Client Transactions
A. Do you or any related person:

Yes

No

Yes

No

Yes

No

Yes

No

(1) buy securities for yourself from advisory clients, or sell securities you own to
advisory clients (principal transactions)?
(2) buy or sell for yourself securities (other than shares of mutual funds) that you
also recommend to advisory clients?
(3) recommend securities (or other investment products) to advisory clients in
which you or any related person has some other proprietary (ownership)
interest (other than those mentioned in Items 8.A.(1) or (2))?
Sales Interest in Client Transactions
B. Do you or any related person:
(1) as a broker-dealer or registered representative of a broker-dealer, execute
securities trades for brokerage customers in which advisory client securities
are sold to or bought from the brokerage customer (agency cross transactions)?
(2) recommend purchase of securities to advisory clients for which you or any related
person serves as underwriter, general or managing partner, or purchaser
representative?
(3) recommend purchase or sale of securities to advisory clients for which you or any
related person has any other sales interest (other than the receipt of sales
commissions as a broker or registered representative of a broker-dealer)?
Investment or Brokerage Discretion
C. Do you or any related person have discretionary authority to determine the:
(1) securities to be bought or sold for a client’s account?
(2) amount of securities to be bought or sold for a client’s account?
(3) broker or dealer to be used for a purchase or sale of securities
for a client’s account?
(4) commission rates to be paid to a broker or dealer for a client’s securities
transactions?

D. If you answer “yes” to C.(3) above, are any of the brokers or dealers related persons?
E. Do you or any related person recommend brokers or dealers to clients?

FORM ADV
Part 1A
Page 14 of 19

F.

Your Name_____________________
Date_____________________

CRD Number_____________________
SEC 801- or 802 Number_____________________

If you answer “yes” to E above, are any of the brokers or dealers related persons?

G. (1) Do you or any related person receive research or other products or services
other than execution from a broker-dealer or a third party (“soft dollar benefits”) in
connection with client securities transactions?
(2) If “yes” to G.(1) above, are all the “soft dollar benefits” you or any
related persons receive eligible “research or brokerage services” under section
28(e) of the Securities Exchange Act of 1934?
H. Do you or any related person, directly or indirectly, compensate any person for
client referrals?
I.

Do you or any related person, directly or indirectly, receive compensation from any
person for client referrals?
In responding to Items 8.H and 8.I., consider all cash and non-cash compensation that you or a related
person gave to (in answering Item 8.H) or received from (in answering Item 8.I) any person in exchange
for client referrals, including any bonus that is based, at least in part, on the number or amount of client
referrals.

Item 9

Custody

In this Item, we ask you whether you or a related person has custody of client (other than clients that are investment
companies registered under the Investment Company Act of 1940) assets and about your custodial practices.
A. (1) Do you have custody of any advisory clients’:

Yes

No

(a) cash or bank accounts?
(b) securities?
If you are registering or registered with the SEC, answer “No” to Item 9.A.(1)(a) and (b) if you have
custody solely because (i) you deduct your advisory fees directly from your clients’ accounts, or (ii) a
related person has custody of client assets in connection with advisory services you provide to clients, but
you have overcome the presumption that you are not operationally independent (pursuant to Advisers Act
rule 206(4)-(2)(d)(5)) from the related person.
(2) If you checked “yes” to Item 9.A.(1)(a) or (b), what is the approximate amount of client funds and
securities and total number of clients for which you have custody:
U.S. Dollar Amount

Total Number of Clients

(a) $_______________

(b) _______________

If you are registering or registered with the SEC and you have custody solely because you deduct your
advisory fees directly from your clients’ accounts, do not include the amount of those assets and the
number of those clients in your response to Item 9.A.(2). If your related person has custody of client assets
in connection with advisory services you provide to clients, do not include the amount of those assets and
the number of those clients in your response to Item 9.A.(2). Instead, include that information in your
response to Item 9.B.(2).

FORM ADV
Part 1A
Page 15 of 19

Your Name_____________________
Date_____________________

CRD Number_____________________
SEC 801- or 802 Number_____________________

B. (1) In connection with advisory services you provide to clients, do any of your related persons have
custody of any of your advisory clients’:
Yes

No

(a) cash or bank accounts?
(b) securities?
You are required to answer this item regardless of how you answered Item 9.A.(1)(a) or (b).
(2) If you checked “yes” to Item 9.B.(1)(a) or (b), what is the approximate amount of client funds and
securities and total number of clients for which your related persons have custody:
U.S. Dollar Amount

Total Number of Clients

(a) $_______________

(b) _______________

C. If you or your related persons have custody of client funds or securities in connection with advisory
services you provide to clients, check all the following that apply:
(1) A qualified custodian(s) sends account statements at least quarterly to the investors in the
pooled investment vehicle(s) you manage.
(2) An independent public accountant audits annually the pooled investment vehicle(s) that you
manage and the audited financial statements are distributed to the investors in the pools.
(3) An independent public accountant conducts an annual surprise examination of client funds and
securities.
(4) An independent public accountant prepares an internal control report with respect to custodial
services when you or your related persons are qualified custodians for client funds and
securities.
If you checked Item 9.C.(2), C.(3) or C.(4), list in Section 9.C. of Schedule D the accountants that are
engaged to perform the audit or examination or prepare an internal control report. (If you checked Item
9.C.(2), you do not have to list auditor information in Section 9.C. of Schedule D if you already provided
this information with respect to the private funds you advise in Section 7.B.(1) of Schedule D).
D. Do you or your related person(s) act as qualified custodians for your clients in connection with advisory
services you provide to clients?
Yes
No
(1) you act as a qualified custodian
(2) your related person(s) act as qualified custodian(s)
If you checked “yes” to Item 9.D.(2), all related persons that act as qualified custodians (other than any
mutual fund transfer agent pursuant to rule 206(4)-2(b)(1)) must be identified in Section 7.A. of Schedule
D, regardless of whether you have determined the related person to be operationally independent under
rule 206(4)-2 of the Advisers Act.
E. If you are filing your annual updating amendment and you were subject to a surprise examination by an
independent public accountant during your last fiscal year, provide the date (MM/YYYY) the examination
commenced: _______________

FORM ADV
Part 1A
Page 16 of 19
F.

Your Name_____________________
Date_____________________

CRD Number_____________________
SEC 801- or 802 Number_____________________

If you or your related persons have custody of client funds or securities, how many persons, including, but
not limited to, you and your related persons, act as qualified custodians for your clients in connection with
advisory services you provide to clients? _____________

Item 10 Control Persons
In this Item, we ask you to identify every person that, directly or indirectly, controls you.
If you are submitting an initial application or report, you must complete Schedule A and Schedule B. Schedule
A asks for information about your direct owners and executive officers. Schedule B asks for information about
your indirect owners. If this is an amendment and you are updating information you reported on either
Schedule A or Schedule B (or both) that you filed with your initial application or report, you must complete
Schedule C.
A. Does any person not named in Item 1.A. or Schedules A, B, or C, directly or indirectly, control your
management or policies?
Yes
No
If yes, complete Section 10.A. of Schedule D.
B. If any person named in Schedules A, B, or C or in Section 10.A. of Schedule D is a public reporting
company under Sections 12 or 15(d) of the Securities Exchange Act of 1934, please complete Section 10.B.
of Schedule D.

Item 11 Disclosure Information
In this Item, we ask for information about your disciplinary history and the disciplinary history of all your advisory
affiliates. We use this information to determine whether to grant your application for registration, to decide whether
to revoke your registration or to place limitations on your activities as an investment adviser, and to identify
potential problem areas to focus on during our on-site examinations. One event may result in “yes” answers to more
than one of the questions below.
Your advisory affiliates are: (1) all of your current employees (other than employees performing only clerical,
administrative, support or similar functions); (2) all of your officers, partners, or directors (or any person performing
similar functions); and (3) all persons directly or indirectly controlling you or controlled by you. If you are a
“separately identifiable department or division” (SID) of a bank, see the Glossary of Terms to determine who your
advisory affiliates are.
If you are registered or registering with the SEC or if you are an exempt reporting adviser, you may limit your
disclosure of any event listed in Item 11 to ten years following the date of the event. If you are registered or
registering with a state, you must respond to the questions as posed; you may, therefore, limit your disclosure to ten
years following the date of an event only in responding to Items 11.A.(1), 11.A.(2), 11.B.(1), 11.B.(2), 11.D.(4), and
11.H(1)(a). For purposes of calculating this ten-year period, the date of an event is the date the final order,
judgment, or decree was entered, or the date any rights of appeal from preliminary orders, judgments, or decrees
lapsed.
You must complete the appropriate Disclosure Reporting Page (“DRP”) for “yes” answers to the questions in this
Item 11.
Do any of the events below involve you or any of your supervised persons?

Yes

No

FORM ADV
Part 1A
Page 17 of 19

Your Name_____________________
Date_____________________

CRD Number_____________________
SEC 801- or 802 Number_____________________

For “yes” answers to the following questions, complete a Criminal Action DRP:
A. In the past ten years, have you or any advisory affiliate:

Yes

No

(1) been convicted of or pled guilty or nolo contendere (“no contest”) in a
domestic, foreign, or military court to any felony?
(2) been charged with any felony?
If you are registered or registering with the SEC, or if you are reporting as an exempt reporting adviser,
you may limit your response to Item 11.A.(2) to charges that are currently pending.
B. In the past ten years, have you or any advisory affiliate:
(1) been convicted of or pled guilty or nolo contendere (“no contest”) in a domestic,
foreign, or military court to a misdemeanor involving: investments or an
investment-related business, or any fraud, false statements, or omissions,
wrongful taking of property, bribery, perjury, forgery, counterfeiting, extortion,
or a conspiracy to commit any of these offenses?
(2) been charged with a misdemeanor listed in Item 11.B.(1)?
If you are registered or registering with the SEC, or if you are reporting as an exempt reporting adviser,
you may limit your response to Item 11.B.(2) to charges that are currently pending.
For “yes” answers to the following questions, complete a Regulatory Action DRP:
C. Has the SEC or the Commodity Futures Trading Commission (CFTC) ever:
(1) found you or any advisory affiliate to have made a false statement or omission?
(2) found you or any advisory affiliate to have been involved in a violation of SEC
or CFTC regulations or statutes?
(3) found you or any advisory affiliate to have been a cause of an investment-related
business having its authorization to do business denied, suspended, revoked, or
restricted?
(4) entered an order against you or any advisory affiliate in connection with
investment-related activity?
(5) imposed a civil money penalty on you or any advisory affiliate, or ordered you
or any advisory affiliate to cease and desist from any activity?
D. Has any other federal regulatory agency, any state regulatory agency, or any foreign
financial regulatory authority:
(1) ever found you or any advisory affiliate to have made a false statement or
omission, or been dishonest, unfair, or unethical?
(2) ever found you or any advisory affiliate to have been involved in a violation of
investment-related regulations or statutes?

Yes

No

FORM ADV
Part 1A
Page 18 of 19

Your Name_____________________
Date_____________________

CRD Number_____________________
SEC 801- or 802 Number_____________________

(3) ever found you or any advisory affiliate to have been a cause of an investmentrelated business having its authorization to do business denied, suspended,
revoked, or restricted?

Yes

No

Yes

No

(4) in the past ten years, entered an order against you or any advisory affiliate in
connection with an investment-related activity?
(5) ever denied, suspended, or revoked your or any advisory affiliate’s registration or
license, or otherwise prevented you or any advisory affiliate, by order,
from associating with an investment-related business or restricted your or any
advisory affiliate’s activity?
E. Has any self-regulatory organization or commodities exchange ever:
(1) found you or any advisory affiliate to have made a false statement or omission?
(2) found you or any advisory affiliate to have been involved in a violation of its
rules (other than a violation designated as a “minor rule violation” under a plan
approved by the SEC)?
(3) found you or any advisory affiliate to have been the cause of an investmentrelated business having its authorization to do business denied, suspended,
revoked, or restricted?
(4) disciplined you or any advisory affiliate by expelling or suspending
you or the advisory affiliate from membership, barring or suspending you or
the advisory affiliate from association with other members, or otherwise
restricting your or the advisory affiliate’s activities?
F.

Has an authorization to act as an attorney, accountant, or federal contractor granted
to you or any advisory affiliate ever been revoked or suspended?

G. Are you or any advisory affiliate now the subject of any regulatory proceeding that
could result in a “yes” answer to any part of Item 11.C., 11.D., or 11.E.?
For “yes” answers to the following questions, complete a Civil Judicial Action DRP:
H. (1) Has any domestic or foreign court:
(a) in the past ten years, enjoined you or any advisory affiliate in connection with any
investment-related activity?
(b) ever found that you or any advisory affiliate were involved in a violation of
investment-related statutes or regulations?
(c) ever dismissed, pursuant to a settlement agreement, an investment-related
civil action brought against you or any advisory affiliate by a state or foreign
financial regulatory authority?

FORM ADV
Part 1A
Page 19 of 19

Your Name_____________________
Date_____________________

CRD Number_____________________
SEC 801- or 802 Number_____________________

(2) Are you or any advisory affiliate now the subject of any civil proceeding that could
result in a “yes” answer to any part of Item 11.H(1)?

Item 12 Small Businesses
The SEC is required by the Regulatory Flexibility Act to consider the effect of its regulations on small entities. In
order to do this, we need to determine whether you meet the definition of “small business” or “small organization”
under rule 0-7.
Answer this Item 12 only if you are registered or registering with the SEC and you indicated in response to Item
5.F.(2)(c) that you have regulatory assets under management of less than $25 million. You are not required to
answer this Item 12 if you are filing for initial registration as a state adviser, amending a current state registration, or
switching from SEC to state registration.
For purposes of this Item 12 only:
Total Assets refers to the total assets of a firm, rather than the assets managed on behalf of clients. In
determining your or another person’s total assets, you may use the total assets shown on a current balance sheet
(but use total assets reported on a consolidated balance sheet with subsidiaries included, if that amount is
larger).
Control means the power to direct or cause the direction of the management or policies of a person,
whether through ownership of securities, by contract, or otherwise. Any person that directly or indirectly has
the right to vote 25 percent or more of the voting securities, or is entitled to 25 percent or more of the profits, of
another person is presumed to control the other person.
Yes
A. Did you have total assets of $5 million or more on the last day of your most recent
fiscal year?
If “yes,” you do not need to answer Items 12.B. and 12.C.
B. Do you:
(1) control another investment adviser that had regulatory assets under management
(calculated in response to Item 5.F.(2)(c) of Form ADV) $25 million or more on
the last day of its most recent fiscal year?
(2) control another person (other than a natural person) that had total assets of
$5 million or more on the last day of its most recent fiscal year?
C. Are you:
(1) controlled by or under common control with another investment adviser
that had regulatory assets under management (calculated in response to
Item 5.F.(2)(c) of Form ADV) of $25 million or more on the last day of
its most recent fiscal year?
(2) controlled by or under common control with another person (other than a
natural person) that had total assets of $5 million or more on the last day of its
most recent fiscal year?

No

FORM ADV
Schedule A

Your Name_____________________
Date_____________________

SEC File No._____________________
CRD No._____________________

Direct Owners and Executive Officers
1.

Complete Schedule A only if you are submitting an initial application or report. Schedule A asks for information about your direct owners and
executive officers. Use Schedule C to amend this information.

2.

Direct Owners and Executive Officers. List below the names of:
(a) each Chief Executive Officer, Chief Financial Officer, Chief Operations Officer, Chief Legal Officer, Chief Compliance Officer (Chief
Compliance Officer is required if you are registered or applying for registration and cannot be more than one individual), director and any
other individuals with similar status or functions;
(b) if you are organized as a corporation, each shareholder that is a direct owner of 5% or more of a class of your voting securities, unless you
are a public reporting company (a company subject to Section 12 or 15(d) of the Exchange Act);
Direct owners include any person that owns, beneficially owns, has the right to vote, or has the power to sell or direct the sale of, 5% or
more of a class of your voting securities. For purposes of this Schedule, a person beneficially owns any securities: (i) owned by his/her
child, stepchild, grandchild, parent, stepparent, grandparent, spouse, sibling, mother-in-law, father-in-law, son-in-law, daughter-in-law,
brother-in-law, or sister-in-law, sharing the same residence; or (ii) that he/she has the right to acquire, within 60 days, through the exercise
of any option, warrant, or right to purchase the security.
(c) if you are organized as a partnership, all general partners and those limited and special partners that have the right to receive upon
dissolution, or have contributed, 5% or more of your capital;
(d) in the case of a trust that directly owns 5% or more of a class of your voting securities, or that has the right to receive upon dissolution, or
has contributed, 5% or more of your capital, the trust and each trustee; and
(e) if you are organized as a limited liability company (“LLC”), (i) those members that have the right to receive upon dissolution, or have
contributed, 5% or more of your capital, and (ii) if managed by elected managers, all elected managers.

3.

Do you have any indirect owners to be reported on Schedule B?

4.

In the DE/FE/I column below, enter “DE” if the owner is a domestic entity, “FE” if the owner is an entity incorporated or domiciled in a foreign
country, or “I” if the owner or executive officer is an individual.

5.

Complete the Title or Status column by entering board/management titles; status as partner, trustee, sole proprietor, elected manager,
shareholder, or member; and for shareholders or members, the class of securities owned (if more than one is issued).

6.

Ownership codes are:

7.

(a) In the Control Person column, enter “Yes” if the person has control as defined in the Glossary of Terms to Form ADV, and enter “No” if
the person does not have control. Note that under this definition, most executive officers and all 25% owners, general partners, elected
managers, and trustees are control persons.
(b) In the PR column, enter “PR” if the owner is a public reporting company under Sections 12 or 15(d) of the Exchange Act.
(c) Complete each column.

FULL LEGAL NAME
(Individuals: Last Name,
First Name, Middle Name)

NA - less than 5%
A - 5% but less than 10%

DE/FE/I

Yes

No

B - 10% but less than 25%
C - 25% but less than 50%

Title or Status

Date Title
or Status
Acquired
MM YYYY

Ownership
Code

D - 50% but less than 75%
E - 75% or more

Control
Person
PR

CRD No.
If None: S.S. No. and
Date of Birth, IRS Tax No.
or Employer ID No.

FORM ADV
Schedule B

Your Name_____________________
Date_____________________

SEC File No._____________________
CRD No._____________________

Indirect Owners
1.

Complete Schedule B only if you are submitting an initial application or report. Schedule B asks for information about your indirect owners; you
must first complete Schedule A, which asks for information about your direct owners. Use Schedule C to amend this information.

2.

Indirect Owners. With respect to each owner listed on Schedule A (except individual owners), list below:
(a) in the case of an owner that is a corporation, each of its shareholders that beneficially owns, has the right to vote, or has the power to sell or
direct the sale of, 25% or more of a class of a voting security of that corporation;
For purposes of this Schedule, a person beneficially owns any securities: (i) owned by his/her child, stepchild, grandchild, parent,
stepparent, grandparent, spouse, sibling, mother-in-law, father-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law, sharing
the same residence; or (ii) that he/she has the right to acquire, within 60 days, through the exercise of any option, warrant, or right to
purchase the security.
(b) in the case of an owner that is a partnership, all general partners and those limited and special partners that have the right to receive upon
dissolution, or have contributed, 25% or more of the partnership’s capital;
(c) in the case of an owner that is a trust, the trust and each trustee; and
(d) in the case of an owner that is a limited liability company (“LLC”), (i) those members that have the right to receive upon dissolution, or
have contributed, 25% or more of the LLC’s capital, and (ii) if managed by elected managers, all elected managers.

3.

Continue up the chain of ownership listing all 25% owners at each level. Once a public reporting company (a company subject to Sections 12 or
15(d) of the Exchange Act) is reached, no further ownership information need be given.

4.

In the DE/FE/I column below, enter “DE” if the owner is a domestic entity, “FE” if the owner is an entity incorporated or domiciled in a foreign
country, or “I” if the owner is an individual.

5.

Complete the Status column by entering the owner’s status as partner, trustee, elected manager, shareholder, or member; and for shareholders or
members, the class of securities owned (if more than one is issued).

6.

Ownership codes are:

7.

(a) In the Control Person column, enter “Yes” if the person has control as defined in the Glossary of Terms to Form ADV, and enter “No” if
the person does not have control. Note that under this definition, most executive officers and all 25% owners, general partners, elected
managers, and trustees are control persons.
(b) In the PR column, enter “PR” if the owner is a public reporting company under Sections 12 or 15(d) of the Exchange Act.
(c) Complete each column.

FULL LEGAL NAME
(Individuals: Last Name,
First Name, Middle Name)

C - 25% but less than 50%

DE/FE/I

D - 50% but less than 75%

Entity in Which
Interest is Owned

Status

Date
Status
Acquired
MM

YYYY

E - 75% or more

Ownership
Code

F - Other (general partner, trustee,
or elected manager)

Control
Person
PR

CRD No.
If None: S.S. No. and
Date of Birth, IRS Tax No. or
Employer ID No.

FORM ADV
Schedule C

Your Name_____________________
Date_____________________

SEC File No._____________________
CRD No._____________________

Amendments to Schedules A and B
1.

Use Schedule C only to amend information requested on either Schedule A or Schedule B. Refer to Schedule A and Schedule B for specific
instructions for completing this Schedule C. Complete each column.

2.

In the Type of Amendment column, indicate “A” (addition), “D” (deletion), or “C” (change in information about the same person).

3.

Ownership codes are:

NA - less than 5%
A - 5% but less than 10%
B - 10% but less than 25%

C - 25% but less than 50%
D - 50% but less than 75%
E - 75% or more

4. List below all changes to Schedule A (Direct Owners and Executive Officers):
FULL LEGAL NAME
DE/FE/I Type of
Title or
Date Title or
(Individuals: Last Name,
Amendment
Status
Status Acquired
First Name, Middle Name)
MM/YYYY

5. List below all changes to Schedule B (Indirect Owners):
FULL LEGAL NAME
DE/FE/I Type of
Title or
(Individuals: Last Name,
Amendment
Status
First Name, Middle Name)

Date Title or
Status Acquired
MM/YYYY

G - Other (general partner, trustee, or
elected member)

Ownership
Code

Control
Person
PR

Ownership
Code

Control
Person
PR

CRD No.
If None: S.S. No. and
Date of Birth, IRS Tax No.
or Employer ID No.

CRD No.
If None: S.S. No. and
Date of Birth, IRS Tax No.
or Employer ID No.

FORM ADV

Your Name_____________________
CRD Number_____________________
Schedule D
Date_____________________
SEC 801- or 802 Number_____________________
Page 1 of 13
----------------------------------------------------------------------------------------------------------------------------- ---------------------------------Certain items in Part 1A of Form ADV require additional information on Schedule D. Use this Schedule D to report details for items listed below.
Report only new information or changes/updates to previously submitted information. Do not repeat previously submitted information.

----------------------------------------------------------------------------------------------------------------------------- ---------------------------------This is an
INITIAL or
AMENDED Schedule D
SECTION 1.B.

Other Business Names

List your other business names and the jurisdictions in which you use them. You must complete a separate Schedule D Section 1.B. for each
business name.
Check only one box:

Add

Delete

Amend

Name ___________________________________________________________
SECTION 1.F.

Jurisdictions ______________________________

Other Offices

Complete the following information for each office, other than your principal office and place of business, at which you conduct investment advisory
business. You must complete a separate Schedule D Section 1.F. for each location. If you are applying for SEC registration, if you are registered
only with the SEC, or if you are an exempt reporting adviser, list only the largest five offices (in terms of numbers of employees).
Check only one box:

Add

Delete

___________________________________________________________________________________________________________________
(number and street)
___________________________________________________________________________________________________________________
(city)
(state/country)
(zip+4/postal code)
If this address is a private residence, check this box:
_____________________________________
(area code)
(telephone number)

______________________________________
(area code)
(facsimile number)

SECTION 1.I. Website Addresses
List your website addresses. You must complete a separate Schedule D Section 1.I. for each website address.
Check only one box:

Add

Delete

Website Address: ________________________________________________
SECTION 1.L.

Location of Books and Records

Complete the following information for each location at which you keep your books and records, other than your principal office and place of
business. You must complete a separate Schedule D Section 1.L. for each location.
Check only one box:

Add

Delete

Amend

Name of entity where books and records are kept: ___________________________________________________________________________
___________________________________________________________________________________________________________________
(number and street)
__________________________________________________________________________________________________________________
(city)
(state/country)
(zip+4/postal code)
If this address is a private residence, check this box:
_______________________________________
_______________________________________
(area code)
(telephone number)
(area code)
(facsimile number)
This is (check one):

one of your branch offices or affiliates.
a third-party unaffiliated recordkeeper.
other.
Briefly describe the books and records kept at this location. __________________________________________________________________
__________________________________________________________________________________________________________________

FORM ADV

Your Name_____________________
CRD Number_____________________
Schedule D
Date_____________________
SEC 801- or 802 Number_____________________
Page 2 of 13
----------------------------------------------------------------------------------------------------------------------------- ---------------------------------Certain items in Part 1A of Form ADV require additional information on Schedule D. Use this Schedule D to report details for items listed below.
Report only new information or changes/updates to previously submitted information. Do not repeat previously submitted information.

----------------------------------------------------------------------------------------------------------------------------- ---------------------------------This is an
INITIAL or
AMENDED Schedule D
SECTION 1.M.

Registration with Foreign Financial Regulatory Authorities

List the name and country, in English, of each foreign financial regulatory authority with which you are registered. You must complete a separate
Schedule D Section 1.M. for each foreign financial regulatory authority with whom you are registered.
Check only one box:

Add

Delete

Name of Foreign Financial Regulatory Authority ______________________________________
Name of Country ________________________________________________________________________________________________________
SECTION 2.A.(8) Related Adviser
If you are relying on the exemption in rule 203A-2(b) from the prohibition on registration because you control, are controlled by, or are under
common control with an investment adviser that is registered with the SEC and your principal office and place of business is the same as that of the
registered adviser, provide the following information:
Name of Registered Investment Adviser _____________________________________________________________________________
CRD Number of Registered Investment Adviser _____________________________
SEC Number of Registered Investment Adviser 801-___________________________
SECTION 2.A.(9) Newly Formed Adviser
If you are relying on rule 203A-2(c), the newly formed adviser exemption from the prohibition on registration, you are required to make certain
representations about your eligibility for SEC registration. By checking the appropriate boxes, you will be deemed to have made the required
representations. You must make both of these representations:
I am not registered or required to be registered with the SEC or a state securities authority and I have a reasonable expectation that I
will be eligible to register with the SEC within 120 days after the date my registration with the SEC becomes effective.
I undertake to withdraw from SEC registration if, on the 120th day after my registration with the SEC becomes effective, I would be
prohibited by Section 203A(a) of the Advisers Act from registering with the SEC.
SECTION 2.A.(10) Multi-State Adviser
If you are relying on rule 203A-2(d), the multi-state adviser exemption from the prohibition on registration, you are required to make certain
representations about your eligibility for SEC registration. By checking the appropriate boxes, you will be deemed to have made the required
representations.
If you are applying for registration as an investment adviser with the SEC, you must make both of these representations:
I have reviewed the applicable state and federal laws and have concluded that I am required by the laws of 15 or more states to
register as an investment adviser with the state securities authorities in those states.
I undertake to withdraw from SEC registration if I file an amendment to this registration indicating that I would be required by the
laws of fewer than 15 states to register as an investment adviser with the state securities authorities of those states.
If you are submitting your annual updating amendment, you must make this representation:
Within 90 days prior to the date of filing this amendment, I have reviewed the applicable state and federal laws and have concluded
that I am required by the laws of at least 15 states to register as an investment adviser with the state securities authorities in those
states.

FORM ADV

Your Name_____________________
CRD Number_____________________
Schedule D
Date_____________________
SEC 801- or 802 Number_____________________
Page 3 of 13
----------------------------------------------------------------------------------------------------------------------------- ---------------------------------Certain items in Part 1A of Form ADV require additional information on Schedule D. Use this Schedule D to report details for items listed below.
Report only new information or changes/updates to previously submitted information. Do not repeat previously submitted information.

----------------------------------------------------------------------------------------------------------------------------- ---------------------------------This is an
INITIAL or
AMENDED Schedule D
SECTION 2.A.(12) SEC Exemptive Order
If you are relying upon an SEC order exempting you from the prohibition on registration, provide the following information:
Application Number: 803-_______________

Date of order: _________________
(mm/dd/yyyy)

SECTION 2.B. Private Fund Assets
If you check Item 2.B.(2) or (3), what is the amount of the private fund assets that you manage? _____________.
NOTE: “Private fund assets” has the same meaning here as it has under rule 203(m)-1. If you are an investment adviser with its principal office and
place of business outside of the United States only include private fund assets that you manage at a place of business in the United States.
SECTION 4

Successions

Complete the following information if you are succeeding to the business of a currently registered investment adviser. If you acquired more than one
firm in the succession you are reporting on this Form ADV, you must complete a separate Schedule D Section 4 for each acquired firm. See Part 1A
Instruction 4.
Name of Acquired Firm _________________________________________________________
Acquired Firm’s SEC File No. (if any) 801- _____________________

Acquired Firm’s CRD Number (if any) _______________________

SECTION 5.G.(3) Advisers to Registered Investment Companies and Business Development Companies
If you check Item 5.G (3), what is the SEC file number (811 or 814 number) of each of the registered investment companies and business
development companies to which you act as an adviser pursuant to an advisory contract? You must complete a separate Schedule D Section 5.G.(3)
for each registered investment company and business development company to which you act as an adviser.
Check only one box:

Add

Delete

SEC File Number 811- or 814-______________
SECTION 5.I.(2)

Wrap Fee Programs

If you are a portfolio manager for one or more wrap fee programs, list the name of each program and its sponsor. You must complete a separate
Schedule D Section 5.I.(2) for each wrap fee program for which you are a portfolio manager.
Check only one box:

Add

Delete

Amend

Name of Wrap Fee Program ______________________________________________________________________________________________
Name of Sponsor ________________________________________________________________________________________________________

FORM ADV

Your Name_____________________
CRD Number_____________________
Schedule D
Date_____________________
SEC 801- or 802 Number_____________________
Page 4 of 13
----------------------------------------------------------------------------------------------------------------------------- ---------------------------------Certain items in Part 1A of Form ADV require additional information on Schedule D. Use this Schedule D to report details for items listed below.
Report only new information or changes/updates to previously submitted information. Do not repeat previously submitted information.

----------------------------------------------------------------------------------------------------------------------------- ---------------------------------This is an
INITIAL or
AMENDED Schedule D
SECTION 6.A.

Names of Your Other Businesses

If you are actively engaged in other business using a different name, provide that name and the other line(s) of business.
Add

Delete

Amend

Other Business Name: ___________________________________________________________
Other line(s) of business in which you engage using this name: (check all that apply)

(1) broker-dealer (registered or unregistered)
(2) registered representative of a broker-dealer
(3) commodity pool operator or commodity trading advisor (whether registered or exempt from
registration)
(4) futures commission merchant
(5) real estate broker, dealer, or agent
(6) insurance broker or agent
(7) bank (including a separately identifiable department or division of a bank)
(8) trust company
(9) registered municipal advisor
(10) registered security-based swap dealer
(11) major security-based swap participant
(12) accountant or accounting firm
(13) lawyer or law firm
(14) other financial product salesperson (specify): _____________________________________
SECTION 6.B.(2) Description of Primary Business
Describe your primary business (not your investment advisory business):
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
If you engage in that business under a different name, provide that name:
_______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
SECTION 6.B.(3) Description of Other Products and Services
Describe other products or services you sell to your client. You may omit products and services that you listed in Section 6.B.2. above.
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
If you engage in that business under a different name, provide that name:
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
SECTION 7.A.

Financial Industry Affiliations

Complete a separate Schedule D Section 7.A. for each related person listed in Item 7.A.
Check only one box:

Add

Delete

Amend

FORM ADV

Your Name_____________________
CRD Number_____________________
Schedule D
Date_____________________
SEC 801- or 802 Number_____________________
Page 5 of 13
----------------------------------------------------------------------------------------------------------------------------- ---------------------------------Certain items in Part 1A of Form ADV require additional information on Schedule D. Use this Schedule D to report details for items listed below.
Report only new information or changes/updates to previously submitted information. Do not repeat previously submitted information.

----------------------------------------------------------------------------------------------------------------------------- ---------------------------------This is an
INITIAL or
AMENDED Schedule D
1.

Legal Name of Related Person: ________________________________________________________________

2.

Primary Business Name of Related Person: ___________________________________________________________

3.

Related Person’s SEC File Number (if any) (e.g., 801-, 8-, 866-, 802-) __________________

4.

Related Person’s CRD Number (if any): ______________

5.

Related Person is: (check all that apply)

(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(j)
(k)
(l)
(m)
(n)
(o)
(p)

broker-dealer, municipal securities dealer, or government securities broker or dealer
other investment adviser (including financial planners)
registered municipal advisor
registered security-based swap dealer
major security-based swap participant
commodity pool operator or commodity trading advisor (whether registered or exempt from
registration)
futures commission merchant
banking or thrift institution
trust company
accountant or accounting firm
lawyer or law firm
insurance company or agency
pension consultant
real estate broker or dealer
sponsor or syndicator of limited partnerships (or equivalent), excluding pooled
investment vehicles
sponsor, general partner, managing member (or equivalent) of pooled investment vehicles

6.

Do you control or are you controlled by the related person?

Yes

No

7.

Are you and the related person under common control?

Yes

No

8.

(a) Does the related person act as a qualified custodian for your clients in connection with advisory services
you provide to clients?
Yes

No

(b) If you are registering or registered with the SEC and you have answered “yes” to question 8.(a) above, have you overcome the
presumption that you are not operationally independent (pursuant to rule 206(4)-(2)(d)(5)) from the related person and thus are not
required to obtain a surprise examination for your clients’ funds or securities that are maintained at the related person?
Yes

No

(c) If you have answered “yes” to question 8.(a) above, provide the location of the related person’s office responsible for custody of your
clients’ assets:
__________________________________________________
(number and street)
__________________________________________________
(city) (state/country) (zip+4/postal code)
9.

(a) If the related person is an investment adviser, is it exempt from registration?

Yes

No

Yes

No

(b) If the answer is yes, under what exemption? ______
10. (a) Is the related person registered with a foreign financial regulatory authority?

(b) If the answer is yes, list the name and country, in English, of each foreign financial regulatory authority with which the related person
is registered. _____________________________
11. Do you and the related person share any supervised persons?

Yes

No

FORM ADV

Your Name_____________________
CRD Number_____________________
Schedule D
Date_____________________
SEC 801- or 802 Number_____________________
Page 6 of 13
----------------------------------------------------------------------------------------------------------------------------- ---------------------------------Certain items in Part 1A of Form ADV require additional information on Schedule D. Use this Schedule D to report details for items listed below.
Report only new information or changes/updates to previously submitted information. Do not repeat previously submitted information.

----------------------------------------------------------------------------------------------------------------------------- ---------------------------------This is an
INITIAL or
AMENDED Schedule D
12. Do you and the related person share the same physical location?

Yes

No

SECTION 7.B.(1) Private Fund Reporting
Check only one box:
A.

Add

Delete

Amend

PRIVATE FUND

Information About the Private Fund
1.

(a) Name of the private fund: ___________________
(b) Private fund identification number: ___________________

2.

Under the laws of what state or country is the private fund organized:

3.

Name(s) of General Partner, Manager, Trustee, or Directors (or persons serving in a similar capacity):
Check only one box:

Add

Delete

Amend

______________________
4.

The private fund (check all that apply; you must check at least one):
(1) qualifies for the exclusion from the definition of investment company under section 3(c)(1) of the Investment Company Act of
1940
(2) qualifies for the exclusion from the definition of investment company under section 3(c)(7) of the Investment Company Act of
1940

5.

List the name and country, in English, of each foreign financial regulatory authority with which the private fund is registered.
Check only one box:

Add

Delete

Amend

English Name of Foreign Financial Regulatory Authority _______________
6.

(a) Is this a “master fund” in a master-feeder arrangement?

Yes

Name of Country

_______________

No

(b) If yes, what is the name and private fund identification number (if any) of the feeder funds investing in this private fund?
Check only one box:
Add
________
________

Delete

Amend

(c) Is this a “feeder fund” in a master-feeder arrangement?

Yes

No

(d) If yes, what is the name and private fund identification number (if any) of the master fund in which this private fund invests?
Check only one box:
Add
________
________

Delete

Amend

NOTE: You must complete question 6 for each master-feeder arrangement regardless of whether you are filing a single Schedule D,
Section 7.B.(1) for the master-feeder arrangement or reporting on the funds separately.

FORM ADV

Your Name_____________________
CRD Number_____________________
Schedule D
Date_____________________
SEC 801- or 802 Number_____________________
Page 7 of 13
----------------------------------------------------------------------------------------------------------------------------- ---------------------------------Certain items in Part 1A of Form ADV require additional information on Schedule D. Use this Schedule D to report details for items listed below.
Report only new information or changes/updates to previously submitted information. Do not repeat previously submitted information.

----------------------------------------------------------------------------------------------------------------------------- ---------------------------------This is an
INITIAL or
AMENDED Schedule D
7.

If you are filing a single Schedule D, Section 7.B.(1) for a master-feeder arrangement according to the instructions to this Section 7.B.(1),
for each of the feeder funds answer the following questions:
Check only one box:

Add

Delete

Amend

(a) Name of the private fund: ___________
(b) Private fund identification number: ________________
(c) Under the laws of what state or country is the private fund organized:
(d) Name(s) of General Partner, Manager, Trustee, or Directors (or persons serving in a similar capacity):
Check only one box:

Add

Delete

Amend

______________________
(e) The private fund (check all that apply; you must check at least one):
(1) qualifies for the exclusion from the definition of investment company under section 3(c)(1) of the Investment Company
Act of 1940
(2) qualifies for the exclusion from the definition of investment company under section 3(c)(7) of the Investment Company
Act of 1940
(f)

List the name and country, in English, of each foreign financial regulatory authority with which the private fund is registered.
Check only one box:

Add

Delete

Amend

English Name of Foreign Financial Regulatory Authority _______________

Name of Country

_______________

NOTE: For purposes of questions 6 and 7, in a master-feeder arrangement, one or more funds (“feeder funds”) invest all or substantially all
of their assets in a single fund (“master fund”). A fund would also be a “feeder fund” investing in a “master fund” for purposes of this
question if it issued multiple classes (or series) of shares or interests, and each class (or series) invests substantially all of its assets in a
single master fund.
8.

(a) Is this private fund a “fund of funds”?

Yes

No

(b) If yes, does the private fund invest in funds managed by you or by a related person?

Yes

No

NOTE: For purposes of this question only, answer “yes” if the fund invests 10 percent or more of its total assets in other pooled investment
vehicles, whether or not they are also private funds, or registered investment companies.
9.

During your last fiscal year, did the private fund invest in securities issued by investment companies registered under the Investment
Company Act of 1940 (other than “money market funds,” to the extent provided in Instruction 6.e.)?
Yes
No

10. What type of fund is the private fund?
hedge fund

liquidity fund

private equity fund

real estate fund

securitized asset fund

venture capital fund

Other private fund: _____________
NOTE: For funds of funds, refer to the funds in which the private fund invests. For definitions of these fund types, please see Instruction 6
of the Instructions to Part 1A.
11. Current gross asset value of the private fund: $_____

FORM ADV

Your Name_____________________
CRD Number_____________________
Schedule D
Date_____________________
SEC 801- or 802 Number_____________________
Page 8 of 13
----------------------------------------------------------------------------------------------------------------------------- ---------------------------------Certain items in Part 1A of Form ADV require additional information on Schedule D. Use this Schedule D to report details for items listed below.
Report only new information or changes/updates to previously submitted information. Do not repeat previously submitted information.

----------------------------------------------------------------------------------------------------------------------------- ---------------------------------This is an
INITIAL or
AMENDED Schedule D

Ownership
12. Minimum investment commitment required of an investor in the private fund: $_______________
NOTE: Report the amount routinely required of investors who are not your related persons (even if different from the amount set forth in
the organizational documents of the fund).
13. Approximate number of the private fund’s beneficial owners: ____
14. What is the approximate percentage of the private fund beneficially owned by you and your related persons:
_____ %
15. What is the approximate percentage of the private fund beneficially owned (in the aggregate) by funds of funds:
_____ %
16. What is the approximate percentage of the private fund beneficially owned by non-United States persons:
_____ %
Your Advisory Services
17. (a) Are you a subadviser to this private fund?

Yes

No

(b) If the answer to question 17(a) is “yes,” provide the name and SEC file number, if any, of the adviser of the private fund. If the
answer to question 17(a) is “no,” leave this question blank. ______________
18. (a) Do any other investment advisers advise the private fund?

Yes

No

(b) If the answer to question 18(a) is “yes,” provide the name and SEC file number, if any, of the other advisers to the private fund. If the
answer to question 18(a) is “no,” leave this question blank.
Check only one box:

Add

Delete

______________

______________

Amend

19. Are your clients solicited to invest in the private fund?

Yes

No

20. Approximately what percentage of your clients has invested in the private fund? ______%
Private Offering
21. Does the private fund rely on an exemption from registration of its securities under Regulation D of the Securities Act of 1933?
Yes
No
22. If yes, provide the private fund’s Form D file number (if any):
Check only one box:
021-

Add

Delete

Amend

FORM ADV

Your Name_____________________
CRD Number_____________________
Schedule D
Date_____________________
SEC 801- or 802 Number_____________________
Page 9 of 13
----------------------------------------------------------------------------------------------------------------------------- ---------------------------------Certain items in Part 1A of Form ADV require additional information on Schedule D. Use this Schedule D to report details for items listed below.
Report only new information or changes/updates to previously submitted information. Do not repeat previously submitted information.

----------------------------------------------------------------------------------------------------------------------------- ---------------------------------This is an
INITIAL or
AMENDED Schedule D
B.

SERVICE PROVIDERS
Check this box if you are filing this Form ADV through the IARD system and want the IARD system to create a new Schedule D, Section
7.B.(1) with the same service provider information you have given here in Questions 23 - 28 for a new private fund for which you are required
to complete Section 7.B.(1) If you check the box, the system will pre-fill those fields for you, but you will be able to manually edit the
information after it is pre-filled and before you submit your filing.

Auditors
23. (a) (1) Are the private fund’s financial statements subject to an annual audit?

Yes

No

(2) Are the financial statements prepared in accordance with U.S. GAAP?

Yes

No

If the answer to 23(a)(1) is “yes,” respond to questions (b) through (f) below. If the private fund uses more than one auditing firm,
you must complete questions (b) through (f) separately for each auditing firm.
Check only one box:

Add

Delete

Amend

(b) Name of the auditing firm: ______________________________________________________
(c) The location of the auditing firm’s office responsible for the private fund’s audit (city, state and country): _________________
(d) Is the auditing firm an independent public accountant?

Yes

No

(e) Is the auditing firm registered with the Public Company Accounting Oversight Board?

Yes

No

(f)

If “yes” to (e) above, is the auditing firm subject to regular inspection by the Public Company Accounting Oversight Board in
accordance with its rules?
Yes
No

(g) Are the private fund’s audited financial statements distributed to the private fund’s investors?
(h) Does the report prepared by the auditing firm contain an unqualified opinion?

Yes

Yes
No

No
Report Not Yet Received

If you check “Report Not Yet Received,” you must promptly file an amendment to your Form ADV to update your response when the report is
available.

Prime Broker
24. (a) Does the private fund use one or more prime brokers?

Yes

No

If the answer to 24(a) is “yes,” respond to questions (b) through (e) below for each prime broker the private fund uses. If the private
fund uses more than one prime broker, you must complete questions (b) through (e) separately for each prime broker.
Check only one box:

Add

Delete

Amend

(b) Name of the prime broker: __________
(c) If the prime broker is registered with the SEC, its registration number: 8-_____________
(d) Location of prime broker’s office used principally by the private fund (city, state and country):
________________________________
(e) Does this prime broker act as custodian for some or all of the private fund’s assets?

Yes

No

Custodian
25. (a) Does the private fund use any custodians (including the prime brokers listed above) to hold some or all of its assets?

Yes

No

If the answer to 25(a) is “yes,” respond to questions (b) through (f) below for each custodian the private fund uses. If the private fund
uses more than one custodian, you must complete questions (b) through (f) separately for each custodian.

FORM ADV

Your Name_____________________
CRD Number_____________________
Schedule D
Date_____________________
SEC 801- or 802 Number_____________________
Page 10 of 13
----------------------------------------------------------------------------------------------------------------------------- ---------------------------------Certain items in Part 1A of Form ADV require additional information on Schedule D. Use this Schedule D to report details for items listed below.
Report only new information or changes/updates to previously submitted information. Do not repeat previously submitted information.

----------------------------------------------------------------------------------------------------------------------------- ---------------------------------This is an
INITIAL or
AMENDED Schedule D
Check only one box:

Add

Delete

Amend

(b) Legal name of custodian: _________________________________
(c) Primary business name of custodian: _________________________________
(d) The location of the custodian’s office responsible for custody of the private fund’s assets (city, state and country): ______________
(e) Is the custodian a related person of your firm?
(f)

Yes

No

If the custodian is a broker-dealer, provide its SEC registration number (if any) 8-_______________

Administrator
26. (a) Does the private fund use an administrator other than your firm?

Yes

No

If the answer to 26(a) is “yes,” respond to questions (b) through (f) below. If the private fund uses more than one administrator, you
must complete questions (b) through (f) separately for each administrator.
Check only one box:

Add

Delete

Amend

(b) Name of administrator: _________________________________
(c) Location of administrator (city, state and country): ____________________________________
(d) Is the administrator a related person of your firm?

Yes

No

(e) Does the administrator prepare and send investor account statements to the private fund’s investors?
Yes (provided to all investors)
(f)

Some (provided to some but not all investors)

No (provided to no investors)

If the answer to 26(e) is “no” or “some,” who sends the investor account statements to the (rest of the) private fund’s investors? If
investor account statements are not sent to the (rest of the) private fund’s investors, respond “not applicable.”
__________________________________________.

27. During your last fiscal year, what percentage of the private fund’s assets (by value) was valued by a person, such as an administrator, that
is not your related person?
_____________%
Include only those assets where (i) such person carried out the valuation procedure established for that asset, if any, including obtaining any
relevant quotes, and (ii) the valuation used for purposes of investor subscriptions, redemptions or distributions, and fee calculations
(including allocations) was the valuation determined by such person.
Marketers
28. (a) Does the private fund use the services of someone other than you or your employees for marketing purposes?

Yes

No

You must answer “yes” whether the person acts as a placement agent, consultant, finder, introducer, municipal advisor or other solicitor, or
similar person. If the answer to 28(a) is “yes”, respond to questions (b) through (g) below for each such marketer the private fund uses. If
the private fund uses more than one marketer, you must complete questions (b) through (g) separately for each marketer.
Check only one box:

Add

Delete

Amend

FORM ADV

Your Name_____________________
CRD Number_____________________
Schedule D
Date_____________________
SEC 801- or 802 Number_____________________
Page 11 of 13
----------------------------------------------------------------------------------------------------------------------------- ---------------------------------Certain items in Part 1A of Form ADV require additional information on Schedule D. Use this Schedule D to report details for items listed below.
Report only new information or changes/updates to previously submitted information. Do not repeat previously submitted information.

----------------------------------------------------------------------------------------------------------------------------- ---------------------------------This is an
INITIAL or
AMENDED Schedule D
(b) Is the marketer a related person of your firm?

Yes

No

(c) Name of the marketer: ______________________________________
(d) If the marketer is registered with the SEC, its file number (e.g., 801-, 8-, or 866-): ____________ and
CRD Number (if any) _____________
(e) Location of the marketer’s office used principally by the private fund (city, state and country):
__________________________________
(f)

Does the marketer market the private fund through one or more websites?

Yes

No

(g) If the answer to 28(f) is “yes,” list the website address(es): ___________

SECTION 7.B.(2) Private Fund Reporting
(1) Name of the private fund _______________________
(2) Private fund identification number ____________
(3) Name and SEC File number of adviser that provides information about this private fund in Section 7.B.(1) of Schedule D of its Form ADV
filing __________________________, 801- ____________
or 802-______________
(4) Are your clients solicited to invest in this private fund?

Yes

No

In answering this question, disregard feeder funds’ investment in a master fund. For purposes of this question, in a master-feeder
arrangement, one or more funds (“feeder funds”) invest all or substantially all of their assets in a single fund (“master fund”). A fund
would also be a “feeder fund” investing in a “master fund” for purposes of this question if it issued multiple classes (or series) of shares or
interests, and each class (or series) invests substantially all of its assets in a single master fund.
SECTION 9.C. Independent Public Accountant
You must complete the following information for each independent public accountant engaged to perform a surprise examination, perform an audit
of a pooled investment vehicle that you manage, or prepare an internal control report. You must complete a separate Schedule D Section 9.C. for
each independent public accountant.
Check only one box:

Add

Delete

Amend

(1) Name of the independent public accountant: _________________________________________
(2) The location of the independent public accountant’s office responsible for the services provided:
___________________________________________________________________________________________________________________
(number and street)
___________________________________________________________________________________________________________________
(city)
(state/country)
(zip+4/postal code)
(3) Is the independent public accountant registered with the Public Company Accounting Oversight Board?

Yes

No

(4) If yes to (3) above, is the independent public accountant subject to regular inspection by the Public Company Accounting Oversight Board in
accordance with its rules?
Yes
No
(5) The independent public accountant is engaged to:

FORM ADV

Your Name_____________________
CRD Number_____________________
Schedule D
Date_____________________
SEC 801- or 802 Number_____________________
Page 12 of 13
----------------------------------------------------------------------------------------------------------------------------- ---------------------------------Certain items in Part 1A of Form ADV require additional information on Schedule D. Use this Schedule D to report details for items listed below.
Report only new information or changes/updates to previously submitted information. Do not repeat previously submitted information.

----------------------------------------------------------------------------------------------------------------------------- ---------------------------------This is an
INITIAL or
AMENDED Schedule D
A.
B.
C.

audit a pooled investment vehicle
perform a surprise examination of clients’ assets
prepare an internal control report

(6) Does any report prepared by the independent public accountant that audited the pooled investment vehicle or that examined internal controls
contain an unqualified opinion?
Yes
No
Report Not Yet Received
If you check “Report Not Yet Received,” you must promptly file an amendment to your Form ADV to update your response when the
accountant’s report is available.
SECTION 10.A.

Control Persons

You must complete a separate Schedule D Section 10.A. for each control person not named in Item 1.A. or Schedules A, B, or C that directly or
indirectly controls your management or policies.
Check only one box:

Add

Delete

Amend

(1) Firm or Organization Name
______________________________________________________________________________________________
(2) CRD Number (if any) _______________________

Effective Date _________________
mm/dd/yyyy

Termination Date _________________
mm/dd/yyyy

(3) Business Address:
_____________________________________________________________________________________________________________________
(number and street)
_____________________________________________________________________________________________________________________
(city)
(state/country)
(zip+4/postal code)
If this address is a private residence, check this box:
(4) Individual Name (if applicable) (Last, First, Middle)
___________________________________________________________________________
(5) CRD Number (if any) _______________________

Effective Date _________________
mm/dd/yyyy

Termination Date _________________
mm/dd/yyyy

(6) Business Address:
_____________________________________________________________________________________________________________________
(number and street)
_____________________________________________________________________________________________________________________
(city)
(state/country)
(zip+4/postal code)
If this address is a private residence, check this box:
(7) Briefly describe the nature of the control:
___________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________

SECTION 10.B.

Control Person Public Reporting Companies

If any person named in Schedules A, B, or C, or in Section 10 A. of Schedule D is a public reporting company under Sections 12 or 15(d) of the
Securities Exchange Act of 1934 , please provide the following information (you must complete a separate Schedule D Section 10.B. for each public
reporting company):

FORM ADV

Your Name_____________________
CRD Number_____________________
Schedule D
Date_____________________
SEC 801- or 802 Number_____________________
Page 13 of 13
----------------------------------------------------------------------------------------------------------------------------- ---------------------------------Certain items in Part 1A of Form ADV require additional information on Schedule D. Use this Schedule D to report details for items listed below.
Report only new information or changes/updates to previously submitted information. Do not repeat previously submitted information.

----------------------------------------------------------------------------------------------------------------------------- ---------------------------------This is an
INITIAL or
AMENDED Schedule D
(1) Full legal name of the public reporting company: ___________________________________________________
(2) The public reporting company’s CIK number (Central Index Key number that the SEC assigns to each reporting company):
______________________________
Miscellaneous
You may use the space below to explain a response to an Item or to provide any other information.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

CRIMINAL DISCLOSURE REPORTING PAGE (ADV)

GENERAL INSTRUCTIONS
This Disclosure Reporting Page (DRP ADV) is an  INITIAL OR  AMENDED response used to report details for
affirmative responses to Items 11.A. or 11.B. of Form ADV.
Check item(s) being responded to:

 11.A(1)

 11.A(2)

11.B(1)

11.B(2)

Use a separate DRP for each event or proceeding. The same event or proceeding may be reported for more than one person or
entity using one DRP. File with a completed Execution Page.
Multiple counts of the same charge arising out of the same event(s) should be reported on the same DRP. Unrelated criminal
actions, including separate cases arising out of the same event, must be reported on separate DRPs. Use this DRP to report all
charges arising out of the same event. One event may result in more than one affirmative answer to the items listed above.

PART I
A.

The person(s) or entity(ies) for whom this DRP is being filed is (are):
You (the advisory firm)
You and one or more of your advisory affiliates
One or more of your advisory affiliates
If this DRP is being filed for an advisory affiliate, give the full name of the advisory affiliate below (for individuals, Last
name, First name, Middle name).
If the advisory affiliate has a CRD number, provide that number. If not, indicate "non-registered" by checking the
appropriate box.
Your Name

Your CRD Number

ADV DRP - ADVISORY AFFILIATE
CRD Number

This advisory affiliate is
Registered:

a firm an individual
Yes
No

Name (For individuals, Last, First, Middle)
This DRP should be removed from the ADV record because the advisory affiliate(s) is no longer associated with the
adviser.
This DRP should be removed from the ADV record because: (1) the event or proceeding occurred more than ten years
ago or (2) the adviser is registered or applying for registration with the SEC and the event was resolved in the adviser’s
or advisory affiliate’s favor.
This DRP should be removed from the ADV record because it was filed in error, such as due to a clerical or data-entry
mistake. Explain the circumstances:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
B.

If the advisory affiliate is registered through the IARD system or CRD system, has the advisory affiliate submitted a DRP
(with Form ADV, BD or U-4) to the IARD or CRD for the event? If the answer is “Yes,” no other information on this DRP
must be provided.
Yes
No
NOTE:

The completion of this form does not relieve the advisory affiliate of its obligation to update its IARD or CRD
records.
(continued)

SEC 1707 (09-11)
File 2 of 4

CRIMINAL DISCLOSURE REPORTING PAGE (ADV)
(continuation)
PART II
1.

If charge(s) were brought against an organization over which you or an advisory affiliate exercise(d) control: Enter
organization name, whether or not the organization was an investment-related business and your or the advisory affiliate's
position, title, or relationship.

_______________________________________________________________________________________________________
2.

Formal Charge(s) were brought in: (include name of Federal, Military, State or Foreign Court, Location of Court - City or
County and State or Country, Docket/Case number).

_______________________________________________________________________________________________________
3.

Event Disclosure Detail (Use this for both organizational and individual charges.)
A.

Date First Charged (MM/DD/YYYY):

Exact

Explanation

If not exact, provide explanation: __________________________________________________________________________
B.

Event Disclosure Detail (include Charge(s)/Charge Description(s), and for each charge provide: (1) number of counts,
(2) felony or misdemeanor, (3) plea for each charge, and (4) product type if charge is investment-related).

____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________

C.

Did any of the Charge(s) within the Event involve a felony?

D.

Current status of the Event?

E.

Event Status Date (complete unless status is Pending) (MM/DD/YYYY):
Exact

Pending

Yes

On Appeal

No
Final

Explanation

If not exact, provide explanation: ________________________________________________________________________
4.

Disposition Disclosure Detail: Include for each charge (a) Disposition Type (e.g., convicted, acquitted, dismissed, pretrial,
etc.), (b) Date, (c) Sentence/Penalty, (d) Duration (if sentence-suspension, probation, etc.), (e) Start Date of Penalty, (f)
Penalty/Fine Amount, and (g) Date Paid.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

(continued)

CRIMINAL DISCLOSURE REPORTING PAGE (ADV)
(continuation)
5.

Provide a brief summary of circumstances leading to the charge(s) as well as the disposition. Include the relevant dates
when the conduct which was the subject of the charge(s) occurred. (Your response must fit within the space provided.)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

REGULATORY ACTION DISCLOSURE REPORTING PAGE (ADV)
GENERAL INSTRUCTIONS
This Disclosure Reporting Page (DRP ADV) is an  INITIAL OR  AMENDED response used to report details for
affirmative responses to Items 11.C., 11.D., 11.E., 11.F. or 11.G. of Form ADV.
Check item(s) being responded to:






11.C(1)
11.D(1)
11.E(1)
11.F.






11.C(2)
11.D(2)
11.E(2)
11.G.

 11.C(3)
 11.D(3)
 11.E(3)

 11.C(4)
 11.D(4)
 11.E(4)

 11.C(5)
 11.D(5)

Use a separate DRP for each event or proceeding. The same event or proceeding may be reported for more than one person or
entity using one DRP. File with a completed Execution Page.
One event may result in more than one affirmative answer to Items 11.C., 11.D., 11.E., 11.F. or 11.G. Use only one DRP to
report details related to the same event. If an event gives rise to actions by more than one regulator, provide details for each
action on a separate DRP.
PART I
A.

The person(s) or entity(ies) for whom this DRP is being filed is (are):
You (the advisory firm)
You and one or more of your advisory affiliates
One or more of your advisory affiliates
If this DRP is being filed for an advisory affiliate, give the full name of the advisory affiliate below (for individuals, Last
name, First name, Middle name).
If the advisory affiliate has a CRD number, provide that number. If not, indicate "non-registered" by checking the
appropriate box.
Your CRD Number

Your Name
ADV DRP - ADVISORY AFFILIATE
CRD Number

This advisory affiliate is
Registered:

a firm
Yes

No

an individual

Name (For individuals, Last, First, Middle)
This DRP should be removed from the ADV record because the advisory affiliate(s) is no longer associated with the
adviser.
This DRP should be removed from the ADV record because: (1) the event or proceeding occurred more than ten
years ago or (2) the adviser is registered or applying for registration with the SEC and the event was resolved in the
adviser’s or advisory affiliate’s favor.
If you are registered or registering with a state securities authority, you may remove a DRP for an event you reported only
in response to Item 11.D(4), and only if that event occurred more than ten years ago. If you are registered or registering
with the SEC, you may remove a DRP for any event listed in Item 11 that occurred more than ten years ago.
This DRP should be removed from the ADV record because it was filed in error, such as due to a clerical or data-entry
mistake. Explain the circumstances:
______________________________________________________________________________________________
______________________________________________________________________________________________
B.

If the advisory affiliate is registered through the IARD system or CRD system, has the advisory affiliate submitted a DRP
(with Form ADV, BD or U-4) to the IARD or CRD for the event? If the answer is “Yes,” no other information on this DRP
must be provided.
Yes
No
NOTE:

The completion of this form does not relieve the advisory affiliate of its obligation to update its IARD or CRD
records.
(continued)

SEC 1707 (09-11)
File 2 of 4

PART II
1.

REGULATORY ACTION DISCLOSURE REPORTING PAGE (ADV)
(continuation)

Regulatory Action initiated by:
SEC
Other Federal

State

SRO

Foreign

(Full name of regulator, foreign financial regulatory authority, federal, state or SRO)
_____________________________________________________________________________________________________
2.

Principal Sanction (check appropriate item):
Civil and Administrative Penalty(ies)/Fine(s)
Bar
Cease and Desist
Censure
Denial

Disgorgement
Expulsion
Injunction
Prohibition
Reprimand

Restitution
Revocation
Suspension
Undertaking
Other ______________

Other Sanctions:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________

3.

Date Initiated (MM/DD/YYYY):

Exact

Explanation

If not exact, provide explanation: ________________________________________________________________________

4.

Docket/Case Number:

5.

Advisory Affiliate Employing Firm when activity occurred which led to the regulatory action (if applicable):

6.

Principal Product Type (check appropriate item):
Annuity(ies) - Fixed
Annuity(ies) - Variable
CD(s)
Commodity Option(s)
Debt - Asset Backed
Debt - Corporate
Debt - Government
Debt - Municipal

Derivative(s)
Direct Investment(s) - DPP & LP Interest(s)
Equity - OTC
Equity Listed (Common & Preferred Stock)
Futures - Commodity
Futures - Financial
Index Option(s)
Insurance

Investment Contract(s)
Money Market Fund(s)
Mutual Fund(s)
No Product
Options
Penny Stock(s)
Unit Investment Trust(s)
Other ______________

Other Product Types:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
(continued)

REGULATORY ACTION DISCLOSURE REPORTING PAGE (ADV)
(continuation)
7.

Describe the allegations related to this regulatory action (your response must fit within the space provided):

______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
8.

Current status?

Pending

On Appeal

Final

9.

If on appeal, regulatory action appealed to (SEC, SRO, Federal or State Court) and Date Appeal Filed:

_______________________________________________________________________________________________________
_________________________________________________________________________________________________________
____
If Final or On Appeal, complete all items below. For Pending Actions, complete Item 13 only.
10. How was matter resolved (check appropriate item):
Acceptance, Waiver & Consent (AWC)
Consent
Decision
Decision & Order of Offer of Settlement

Dismissed
Order
Settled
Stipulation and Consent

11. Resolution Date (MM/DD/YYYY):

Vacated
Withdrawn
Other ______________
Exact

Explanation

If not exact, provide explanation: ___________________________________________________________________
12. Resolution Detail:
A.

Were any of the following Sanctions Ordered (check all appropriate items)?
Monetary/Fine
Amount: $

B.

Revocation/Expulsion/Denial
Censure

Disgorgement/Restitution

Cease and Desist/Injunction

Bar

Suspension

Other Sanctions Ordered:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Sanction detail: if suspended, enjoined or barred, provide duration including start date and capacities affected (General
Securities Principal, Financial Operations Principal, etc.). If requalification by exam/retraining was a condition of the
sanction, provide length of time given to requalify/retrain, type of exam required and whether condition has been
satisfied. If disposition resulted in a fine, penalty, restitution, disgorgement or monetary compensation, provide total
amount, portion levied against you or an advisory affiliate, date paid and if any portion of penalty was waived:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
(continued)

REGULATORY ACTION DISCLOSURE REPORTING PAGE (ADV)
(continuation)
13. Provide a brief summary of details related to the action status and (or) disposition and include relevant terms, conditions and
dates (your response must fit within the space provided).
________________________________________________________________________________________________________
____________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
________________________________________________________________________________________________________
_______ ____________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

CIVIL JUDICIAL ACTION DISCLOSURE REPORTING PAGE (ADV)
GENERAL INSTRUCTIONS
This Disclosure Reporting Page (DRP ADV) is an  INITIAL OR  AMENDED response used to report details for
affirmative responses to Item 11.H. of Part 1A and Item 2.F. of Part 1B of Form ADV.
Check Part 1A item(s) being responded to:  11.H(1)(a)
Check Part 1B item(s) being responded to:  2.F(1)

 11.H(1)(b)
 2.F(2)

 11.H(1)(c)
 2.F(3)

 11.H(2)
 2.F(4)

 2.F(5)

Use a separate DRP for each event or proceeding. The same event or proceeding may be reported for more than one person or
entity using one DRP. File with a completed Execution Page.
One event may result in more than one affirmative answer to Item 11.H. of Part 1A or Item 2.F. of Part 1B. Use only one DRP to
report details related to the same event. Unrelated civil judicial actions must be reported on separate DRPs.
PART I
A.

The person(s) or entity(ies) for whom this DRP is being filed is (are):
You (the advisory firm)
You and one or more of your advisory affiliates
One or more of your advisory affiliates





If this DRP is being filed for an advisory affiliate, give the full name of the advisory affiliate below (for individuals, Last
name, First name, Middle name).
If the advisory affiliate has a CRD number, provide that number. If not, indicate "non-registered" by checking the
appropriate box.
Your Name

Your CRD Number

ADV DRP - ADVISORY AFFILIATE
CRD Number

This advisory affiliate is
Registered:

a firm
Yes

an individual
No

Name (For individuals, Last, First, Middle)


This DRP should be removed from the ADV record because the advisory affiliate(s) is no longer associated with the
adviser.



This DRP should be removed from the ADV record because: (1) the event or proceeding occurred more than ten years
ago or (2) the adviser is registered or applying for registration with the SEC and the event was resolved in the adviser’s
or advisory affiliate’s favor.

If you are registered or registering with a state securities authority, you may remove a DRP for an event you reported only
in response to Item 11.H.(1)(a), and only if that event occurred more than ten years ago. If you are registered or registering
with the SEC, you may remove a DRP for any event listed in Item 11 that occurred more than ten years ago.
This DRP should be removed from the ADV record because it was filed in error, such as due to a clerical or data-entry
mistake. Explain the circumstances:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
B.

If the advisory affiliate is registered through the IARD system or CRD system, has the advisory affiliate submitted a DRP
(with Form ADV, BD or U-4) to the IARD or CRD for the event? If the answer is “Yes,” no other information on this DRP
must be provided.
Yes
No
NOTE:

The completion of this form does not relieve the advisory affiliate of its obligation to update its IARD or CRD
records.
(continued)

SEC 1707 (09-11)
File 2 of 4

PART II
1.

CIVIL JUDICIAL ACTION DISCLOSURE REPORTING PAGE (ADV)
(continuation)

Court Action initiated by: (Name of regulator, foreign financial regulatory authority, SRO, commodities exchange, agency,
firm, private plaintiff, etc.)
_____________________________________________________________________________________________________

2.

Principal Relief Sought (check appropriate item):
Cease and Desist
Civil Penalty(ies)/Fine(s)

Disgorgement
Injunction

Money Damages (Private/Civil Complaint)
Restitution

Restraining Order
Other _________

Other Relief Sought:
____________________________________________________________________________________________________
____________________________________________________________________________________________________

3.

Filing Date of Court Action (MM/DD/YYYY):



Exact



Explanation

If not exact, provide explanation: _________________________________________________________________________
4.

Principal Product Type (check appropriate item):
Annuity(ies) - Fixed
Annuity(ies) - Variable
CD(s)
Commodity Option(s)
Debt - Asset Backed
Debt - Corporate
Debt - Government
Debt - Municipal

Derivative(s)
Direct Investment(s) - DPP & LP Interest(s)
Equity - OTC
Equity Listed (Common & Preferred Stock)
Futures - Commodity
Futures - Financial
Index Option(s)
Insurance

Investment Contract(s)
Money Market Fund(s)
Mutual Fund(s)
No Product
Options
Penny Stock(s)
Unit Investment Trust(s)
Other ______________

Other Product Types:
_____________________________________________________________________________________________________
5.

Formal Action was brought in (include name of Federal, State or Foreign Court, Location of Court - City or County and
State or Country, Docket/Case Number):

_____________________________________________________________________________________________________
6.

Advisory Affiliate Employing Firm when activity occurred which led to the civil judicial action (if applicable):

(continued)

CIVIL JUDICIAL ACTION DISCLOSURE REPORTING PAGE (ADV)
(continuation)
7.

Describe the allegations related to this civil action (your response must fit within the space provided):

______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
8.

Current status?

Pending

On Appeal

Final

9.

If on appeal, action appealed to (provide name of court) and Date Appeal Filed (MM/DD/YYYY):

_____________________________________________________________________________________________________
_____________________________________________________________________________
10. If pending, date notice/process was served (MM/DD/YYYY):

Exact

Explanation

If not exact, provide explanation: _________________________________________________________________________
If Final or On Appeal, complete all items below. For Pending Actions, complete Item 14 only.
11. How was matter resolved (check appropriate item):
Consent
Dismissed

Judgment Rendered
Opinion

Settled
Withdrawn

12. Resolution Date (MM/DD/YYYY):

Exact

Other _____________
Explanation

If not exact, provide explanation: __________________________________________________________________
13. Resolution Detail:
A.

Were any of the following Sanctions Ordered or Relief Granted (check appropriate items)?
Monetary/Fine
Amount: $

B.

Revocation/Expulsion/Denial
Censure

Disgorgement/Restitution

Cease and Desist/Injunction

Bar

Suspension

Other Sanctions:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

(continued)

CIVIL JUDICIAL ACTION DISCLOSURE REPORTING PAGE (ADV)
(continuation)
C.

Sanction detail: if suspended, enjoined or barred, provide duration including start date and capacities affected (General
Securities Principal, Financial Operations Principal, etc.). If requalification by exam/retraining was a condition of the
sanction, provide length of time given to requalify/retrain, type of exam required and whether condition has been
satisfied. If disposition resulted in a fine, penalty, restitution, disgorgement or monetary compensation, provide total
amount, portion levied against you or an advisory affiliate, date paid and if any portion of penalty was waived:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

14. Provide a brief summary of circumstances related to the action(s), allegation(s), disposition(s) and/or finding(s) disclosed
above (your response must fit within the space provided).
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________