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Monthly Report - Under subsection 11(2) of the Regulations Implementing the United Nations Resolutions on the Democratic People's Republic of Korea (UNRDPRK) or subsection 11(2) of the Regulations Implementing the United Nations Resolution on IRAN (RIUNRI) Long Form Version The LONG FORM version can be used by registrants to file a POSITIVE REPORT only. See "Instructions" and "Notes" on pages 2-3. To file a NIL Report, please use the SHORT FORM version. Name Of Registrant: Date of filing of this report: Address: Monthly period covered in this report: (see Note 2) Adviser Investment Counsel Investment Dealer and Dealer (FCM) Type of Registration: (check all applicable categories) Portfolio Manager Securities Adviser Other (would include such categories as Dealer/Floor Broker, Local Dealer/Merchant, and Specific Securities Dealer Yes The above Registrant has accounts in the name of a Designated Person*, or has contracts with a Designated Person, or possesses or controls property that is owned or controlled by or on behalf of a Designated Person. *Please refer to the definitions below for the definition of "Designated Person". Please complete the table below and the certificate at the end of this form. C O N F I D E N T I A L Revised June 7, 2007 ____ / ____ / ____ (dd / mm / yy) ____ / ____ / ____ (dd / mm / yy) to ____ / ____ / ____ (dd / mm / yy) Dealer (Floor Commission Merchant) Investment Dealer Mutual Fund Dealer Scholarship Plan Dealer
Definitions: • "Number of Accounts" means the number of accounts, policies or contracts associated with a Designated Person. • "Designated Person" is defined in section 1 of the UNRDPRK and section 1 of the RIUNRI. • "Property" is defined in section 1 of the UNRDPRK and section 1 of the RIUNRI and includes assets under administration (both discretionary and non-discretionary). SUMMARY OF PROPERTY (see Note 3) Type of Property Number of Accounts Property Value (Canadian $) (see Note 2) (see Note 3) Cash, cash equivalents, demand and term deposits Securities (bonds, debentures, commercial paper, treasury bills, mutual fund units, scholarship plan units, common and preferred shares and derivatives). Loans (including, mortgages, overdrafts, credit card balances, term loans, lines of credit and other indebtedness) Annuities (cash surrender value/monthly income) Life insurance policies Property & casualty insurance policies (policy limit) Other property, including real estate Totals Certificate The Undersigned certifies that, to the best of his/her knowledge, and after having made reasonable enquiries, the information contained in this report is correct, any property summarized in this report has been frozen and the relevant account details have been reported to the Royal Canadian Mounted Police and the Canadian Security Intelligence Service and in respect of any foreign operations, to foreign law enforcement officials, as appropriate. Name Signature Title Telephone Date (dd/mm/yyyy): Instructions: This report must be filed by every entity that is authorized under provincial legislation to engage in the business of dealing in securities, or to provide portfolio management or investment counseling services ("Registrants"). (See Note 1.) The report must be filed with The Manitoba Securities Commission by fax at (204) 945-0330 no later than the fifteenth (15 th ) day of each calendar month. If such day falls on a Saturday, Sunday or statutory holiday, the report is due on the next business day. The reporting month is the month on which the report is based (e.g. for the report due on December 15, the reporting month would be November). You must review your records on a continuing basis for any dealings with Designated Persons. You must consult the updated combined list of names posted on the website of the Office of the Superintendent of Financial Institutions (OSFI) before filing the report: www.osfi-bsif.gc.ca.
Notes: These Notes are provided as general information only. They do not constitute legal advice, and are not intended to replace the laws referred to in this report. You should refer to these laws for full details regarding your obligations. 1. The information required in this report is required pursuant to section 11 of the Regulations Implementing the United Nations Resolutions on the Democratic People's Republic of Korea (UNRDPRK) or section 11 of the Regulations Implementing the United Nations Resolution on Iran (RIUNRI). A report must be filed by all entities authorized under provincial legislation to engage in the business of dealing in securities or provide portfolio management or investment counseling services. Members of the Investment Dealers Association of Canada (IDA) are requested to use the appropriate reporting form issued by, and to file that form with, the IDA. 2. All reports must cover continuous dates and there must be no gaps in the reporting periods starting with the first day of each month and ending with the last day. The report is cumulative; therefore, you must continue to include information reported in a previous report, provided that the information remains unchanged. The long form report is only to be used where assets have been frozen AND reported to the RCMP. As indicated in Note 6 below, in all other situations the simplified report (short form) should be used. 3. All amounts must be stated in Canadian dollars. NOTE: If the original amount of the property frozen is denominated in a currency other than Canadian dollars, then the Canadian dollar equivalent should be reported using the same rate of exchange that was in effect on the date that the property was originally frozen and reported to law enforcement. 4. You must include information from any branches located outside Canada. 5. This is an aggregate report of dealings that Registrants have with Designated Persons. Do not append personal information or account or policy information. Such information must be directed to the Royal Canadian Mounted Police, the Canadian Security Intelligence Service, and if applicable, and, in respect of any foreign operations, to foreign law enforcement officials. 6. If there are no assets frozen, you may use the simplified reporting form (short form) to confirm this. This includes situations where you may be seeking clarification from the authorities about whether an account holder is in fact a Designated Person; in other words you may make the simplified (short form) filing where you have not made a determination that you are dealing with a Designated Person. There is no need to report numbers of accounts where you are still seeking clarification from the authorities. Reminder: Section 12 of the Regulations Implementing the United Nations Resolution on the Democratic People's of Korea and section 12 of the Regulations Implementing the United Nations Resolution on Iran require every person in Canada and every Canadian outside Canada to disclose without delay to the Royal Canadian Mounted Police and the Canadian Security Intelligence Service (a) the existence of property in their possession or control that is owned or controlled by or on behalf of a Designated Person, and (b) information about a transaction or proposed transaction in respect of property in their possession or control that is owned or controlled by or on behalf of a Designated Person.
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