260.2413 241 2 DBO260.241.2b

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STATE OF CALIFORNIA –DEPARTMENT OF BUSINESS OVERSIGHT

VERIFICATION FORM

DBO - 260.241.2(b) (Rev. 7-13)

TO THE COMMISSIONER OF BUSINESS
OVERSIGHT OF THE STATE OF CALIFORNIA
VERIFICATION FORM PURSUANT TO CALIFORNIA
CODE OF REGULATIONS RULE 260.241.2(b)
(Executed WITHIN or WITHOUT of the State of California)

I,

, declare under penalty of perjury under the laws of the

State of California that I have read the annexed financial report and supporting schedules
and know the contents thereof to be true and correct to my best knowledge and belief;
and neither the licensee nor any partner, officer, or director thereof have any proprietary
interest in any account classified solely as that of a customer.

Executed this

day of

City

at

State

(Signature of person signing report)

(Title of person signing report)

(Name of Licensee)

(File Number)

INSTRUCTIONS:
If the broker-dealer or investment adviser is a sole proprietorship, the verification shall be
made by the proprietor; if a partnership, by a general partner; or if a corporation, by a
duly authorized officer.



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