Unofficial Consolidated Versions

Decision Information

Decision Content

FORM 33-109F5 CHANGE OF REGISTRATION INFORMATION (sections 3.1 and 4.1 ) GENERAL INSTRUCTIONS

Complete and submit this form to notify the relevant regulator(s) or, in Québec, the securities regulatory authority, or self-regulatory organization (SRO) of changes to information in the following forms:

Form 33-109F6, except for the changes set out in section 3.1 of National Instrument 33-109, or Form 33-109F4. How to submit this form To report changes to information in a Form 33-109F4, submit this form at the National Registration Database website in NRD format at www.nrd.ca.

Submit this form in a format other than NRD format to report changes to information in a: a) Form 33-109F6, or b) Form 33-109F4, if the individual is relying on the temporary hardship exemption in section 5.1 of National Instrument 31-102 National Registration Database.

Name of firm ___________________________________________________________________________ Registration categories ___________________________________________________________________ NRD number (firm) ___________________________________ Item 1 Type of form Check the form that is being updated: Form 33-109F6 If submitting changes to Form 33-109F6, please attach a blackline of the amended sections of the form. Form 33-109F4 Name of individual _____________________________________ Item 2 Details of change Provide the item number and details for each change to the form selected above: Item number ________ Details ________________________________________________________________________ Effective date of change _____________________________________ (YYYY/MM/DD)

Item 3 Notice of collection and use of personal information The personal information required under this form is collected on behalf of, and used by, the securities regulatory authorities in the jurisdictions set out in Schedule A to administer and enforce certain provisions of their securities legislation or derivatives legislation or both.

The personal information required under this form is also collected by and used by the SRO set out in Schedule A to administer and enforce its by-laws, regulations, rules, rulings and policies.

By submitting this form, the individual consents to the collection by the securities regulatory authorities or applicable SRO of this personal information, and any police records, records from other government or non-governmental regulators or SROs, credit records and employment records about the individual that the securities regulatory authorities or applicable SRO may need to complete their review of the information submitted in this form relating to the individual’s continued fitness for registration or approval, if applicable, in accordance with the legal authority of the securities regulatory authorities while the individual is registered with or approved by it. Securities regulatory authorities or SROs may contact government and private bodies or agencies, individuals, corporations and other organizations for information about the individual.

If you have any questions about the collection and use of this information, contact the securities regulatory authorities or applicable SRO in any jurisdiction in which the required information is submitted. See Schedule A for details. In Québec, you can also contact the Commission d’accès à l’information at 1-888-528-7741 or visit its website at www.cai.gouv.qc.ca.

Item 4 Warning It is an offence under securities legislation and derivatives legislation, including commodity futures legislation, to give false or misleading information on this form.

Item 5 Certification 1. Use the following certification when submitting this form in NRD format when making changes to Form 33-109F4

I confirm I have discussed the questions in this form with an officer, branch manager or supervisor of my sponsoring firm. To the best of my knowledge and belief, the officer, branch manager or supervisor was satisfied that I fully understood the questions. I will limit my activities to those permitted by my category of registration.

I am making this submission as agent for the individual identified in this form. By checking this box, I certify that the individual provided me with all of the information on this form.

2. Use the following certification when submitting this form in a format other than NRD format when making changes to Form 33-109F6

By signing below I certify to each regulator or, in Québec, the securities regulatory authority, in each jurisdiction where I am submitting this form, either directly or through the principal regulator, that:

I have read this form and understand the questions, and all of the information provided on this form is true, and complete. Name of authorized signing officer or partner ________________________________________________________ Title of authorized signing officer or partner _________________________________________________________ Signature of authorized signing officer or partner _____________________________________________________ Date signed ________________________ (YYYY/MM/DD)

3. Use the following certification when submitting this form in a format other than NRD format under the temporary hardship exemption in section 5.1 of NI 31-102 National Registration Database when making changes to Form 33-109F4

By signing below, I certify to the regulator or, in Québec, the securities regulatory authority, in each jurisdiction where I am submitting this form, either directly or through the principal regulator, that:

I have read this form and understand the questions; and all of the information provided on this form is true and complete. Signature of individual ______________________________________ Date signed ________________________ (YYYY/MM/DD)

Schedule A Contact information for Notice of collection and use of personal information

Alberta Alberta Securities Commission Suite 600, 250–5th St. SW Calgary, AB T2P 0R4 Attention: Information Officer Telephone: (403) 297-6454

British Columbia British Columbia Securities Commission P.O. Box 10142, Pacific Centre 701 West Georgia Street Vancouver, BC V7Y 1L2 Attention: Freedom of Information Officer Telephone: (604) 899-6500 or (800) 373-6393 (in Canada)

Manitoba The Manitoba Securities Commission 500 - 400 St. Mary Avenue Winnipeg, MB R3C 4K5 Attention: Director of Registrations Telephone: (204) 945-2548 Fax: (204) 945-0330 New Brunswick Financial and Consumer Services Commission of New Brunswick / Commission des services financiers et des services aux consommateurs du Nouveau-Brunswick Suite 300, 85 Charlotte Street Saint John, NB E2L 2J2 Attention: Director of Securities Telephone: (506) 658-3060

Newfoundland and Labrador Superintendent of Securities, Service NL Government of Newfoundland and Labrador P.O. Box 8700 2nd Floor, West Block Confederation Building St. John's, NL A1B 4J6 Attention: Manager of Registrations Telephone: (709) 729-5661

Nova Scotia Nova Scotia Securities Commission Suite 400, 5251 Duke Street Halifax, NS B3J 1P3 Attention: Deputy Director, Capital Markets Telephone: (902) 424-7768

Northwest Territories Government of the Northwest Territories Department of Justice 1 st Floor Stuart M. Hodgson Building 5009 49 th Street Yellowknife, NWT X1A 2L9 Attention: Deputy Superintendent of Securities Telephone: (867) 920-8984

Nunavut Government of Nunavut Department of Justice P.O. Box 1000 Station 570 Iqaluit, NU X0A 0H0 Attention: Deputy Registrar of Securities Telephone: (867) 975-6590

Ontario Ontario Securities Commission 22 nd Floor 20 Queen Street West Toronto, ON M5H 3S8 Attention: Compliance and Registrant Regulation Telephone: (416) 593-8314 e-mail: registration@osc.gov.on.ca

Prince Edward Island Securities Office Department of Community Affairs and Attorney General P.O. Box 2000 Charlottetown, PE C1A 7N8 Attention: Deputy Registrar of Securities Telephone: (902) 368-6288 Québec Autorité des marchés financiers 800, square Victoria, 22e étage C.P. 246, tour de la Bourse Montréal (Québec) H4Z 1G3 Attention: Responsable de l’accès à l’information Telephone: (514) 395-0337 or (877) 525-0337

Saskatchewan Financial and Consumer Affairs Authority of Saskatchewan Suite 601, 1919 Saskatchewan Drive Regina, SK S4P 4H2 Attention: Deputy Director, Capital Markets Telephone: (306) 787-5871

Yukon Government of Yukon Superintendent of Securities Department of Community Services P.O. Box 2703 C-6 Whitehorse, YT Y1A 2C6 Attention: Superintendent of Securities Telephone: (867) 667-5314

Self-regulatory organization Investment Industry Regulatory Organization of Canada 121 King Street West, Suite 2000 Toronto, Ontario M5H 3T9 Attention: Privacy Officer Telephone: (416) 364-6133 E-mail: PrivacyOfficer@iiroc.ca

Contents of the form This form consists of the following: Part 1 Registration details Part 2 Contact information Part 3 Business history and structure Part 4 Registration history Part 5 Financial condition Part 6 Client relationships Part 7 Regulatory action Part 8 Legal action Part 9 Certification Schedule A Contact information for notice of collection and use of personal information Schedule B Submission to jurisdiction and appointment of agent for service Schedule C Form 31-103F1 Calculation of excess working capital

You are also required to submit the following supporting documents with your completed form: 1. Schedule B Submission to jurisdiction and appointment of agent for service for each jurisdiction where the firm is seeking registration (question 2.4) 2. Business plan, policies and procedures manual, and client agreements (except in Ontario) (question 3.3) 3. Constating documents (question 3.7) 4. Organization chart (question 3.11) 5. Ownership chart (question 3.12) 6. Calculation of excess working capital (question 5.1) 7. Directors’ resolution approving insurance (question 5.7) 8. Audited financial statements (question 5.13) 9. Letter of direction to auditors (question 5.14) How to complete and submit the form The firm is All dollar values are in Canadian dollars. If a question does not apply to the firm, write “n/a” in the space for required to pay the answer. a registration fee in each If the firm is seeking registration in more than one jurisdiction of Canada or category, other than in the jurisdiction of category of restricted dealer, you only need to complete and submit one form. If the firm is seeking Canada where registration as a restricted dealer, submit and file the form with each jurisdiction of Canada where the firm is it is submitting seeking that registration. and filing this form. Refer to You can complete this form: the prescribed fees of the on paper and deliver it to the principal regulator or relevant SRO applicable on paper, scan it and e-mail it to the principal regulator or SRO jurisdiction for details.

If the firm is seeking registration in Ontario, and Ontario is not the firm’s principal regulator, you must also file a copy of this form, without supporting documents, with the Ontario Securities Commission.

You can find contact information for submitting and filing the form in Appendix B of Companion Policy 33-109CP Registration Information.

We may accept the form in other formats. Please check with the regulator before you complete, submit and file the form. If you are completing the form on paper and need more space to answer a question, use a separate sheet of paper and attach it to this form. Clearly identify the question number.

You must include all supporting documents with your submission. We may ask you to provide other information and documents to help determine whether the firm is suitable for registration.

In most of this form, answers are required to questions that apply only to Canadian provinces and territories; you will find that the questions are referenced to “jurisdictions” or “jurisdiction of Canada”. These refer to all provinces and territories of Canada. However, the questions in Part 4 Registration History and Part 7 Regulatory Action are to be answered in respect of any jurisdiction in the world.

It is an offence under securities legislation and derivatives legislation, including commodity futures legislation, to give false or misleading information on this form.

Updating the information on the form See Part 3 of The firm is required to notify the regulator, within specified times, of any changes to the information on this NI 33-109. form by submitting and filing Form 33-109F5 Change of Registration Information. Collection and use of personal information We and the SROs (if applicable) require personal information about the people referred to in this form as part of our review to determine whether the firm is suitable for registration. If the firm is approved, we also require this information to assess whether the firm continues to meet the registration requirements.

We may only: collect the personal information under the requirements in securities legislation or derivatives legislation or both use this information to administer and enforce provisions of the securities legislation or derivatives legislation or both

We may collect personal information from police records, records of other regulators or SROs, credit records, employment records, government and private bodies or agencies, individuals, corporations, and other organizations. We may also collect personal information indirectly.

We may provide personal information about the individuals referred to in this form to other regulators, securities or derivatives exchanges, SROs or similar organizations, if required for an investigation or other regulatory issue.

If anyone referred to in this form has any questions about the collection and use of their personal information, they can contact the regulator or SRO, if applicable, in the relevant jurisdiction of Canada. See Schedule A for details. In Québec, they can also contact the Commission d’accès à l’information du Québec at 1-888-528-7741 or visit its website at www.cai.gouv.qc.ca.

Part 1 Registration details 1.1 Firm’s full legal name Provide the full legal name of the firm as it appears on the firm’s constating documents required under question 3.7. If the firm is a sole proprietorship, provide your first, last and any middle names.

If the firm’s legal name is in English and French, provide both versions.

1.2 Firm’s NRD number For more information, visit www.nrd- info.ca.

1.3 Why are you submitting this form? Complete: To seek initial registration as a firm in one or more jurisdictions of Canada The entire form To add one or more jurisdictions of Canada Questions 1.1, 1.2, 1.4, 1.5, 2.4, 3.9, to the firm’s registration 5.4, 5.6*, and Part 9 To add one or more categories to the firm’s Questions 1.1, 1.2, 1.4, 1.5, 3.1, 5.1, 5.4, registration 5.5, 5.6*, 5.7, 5.8, Part 6 and Part 9 * If the firm is adding Québec as a jurisdiction for registration in the category of mutual fund dealer or scholarship plan dealer, complete question 5.6.

1.4 In what category and jurisdiction is the firm seeking registration? Check all that apply. (a) Categories under securities legislation Jurisdiction Abbreviations Category AB BC MB NB NL NS NT NU ON PE QC SK YT Alberta (AB) British Investment Columbia (BC) dealer Manitoba (MB) Mutual fund New Brunswick dealer (NB) Scholarship Newfoundland plan dealer and Labrador (NL) Exempt Northwest market dealer Territories (NT) Restricted Nova Scotia dealer (NS) Nunavut (NU) Investment Ontario (ON) fund manager Prince Edward Portfolio Island (PE) manager Québec (QC) Saskatchewan Restricted (SK) portfolio Yukon (YT) manager (b) Categories under derivatives legislation (Manitoba and Ontario only) Category Manitoba Dealer (merchant) Dealer (futures commission merchant) Dealer (floor broker) Local Adviser Ontario Commodity trading adviser Commodity trading counsel Commodity trading manager Futures commission merchant

(c) Investment dealers and portfolio managers (Québec only) If the firm is seeking registration in Québec as an investment dealer or a portfolio manager, will the firm also act as a: Derivatives dealer Yes No Derivatives portfolio manager Yes No 1.5 Exemptions Is the firm applying for any exemptions under securities or derivatives legislation? Yes No If yes, provide the following information for each exemption: Type of exemption

Legislation Jurisdiction(s) where the firm has applied for the exemption AB BC MB NB NL NS NT NU ON PE QC SK YT Part 2 Contact information Addresses 2.1 Head office address A post office Address line 1 box on its own is not Address line 2 acceptable for

a head office City Province/territory/state address. Country Postal/zip code Telephone number Fax number Website If the firm’s head office is in Canada, go to question 2.3. If the firm’s head office is not in Canada, go to question 2.2. 2.2 Firms whose head office is not in Canada (a) Does the firm have any business location addresses in Canada? Yes No If yes, provide the firm’s primary Canadian business location address: Address line 1 Address line 2 City Province/territory Postal code

The securities (b) If a firm is not registered in a jurisdiction of Canada, indicate the jurisdiction of Canada in which the regulatory firm expects to conduct most of its activities that require registration as at the end of its current authority in this financial year or conducted most of its activities that require registration as at the end of its most jurisdiction of recently completed financial year. Canada is the firm’s principal AB BC MB NB NL NS NT NU ON PE QC SK YT regulator in Canada.

A post office 2.3 Mailing address box is acceptable for a Same as the head office address mailing address. Address line 1 Address line 2

City Province/territory/state Country Postal/zip code If the firm does 2.4 Address for service and agent for service not have an office in a Attach a completed Schedule B Submission to jurisdiction and appointment of agent for service for jurisdiction of each jurisdiction of Canada where the firm is seeking registration and does not have an office. Canada where it is seeking registration, it must appoint an agent for service in that jurisdiction of Canada. Contact names

2.5 Ultimate designated person A registered Legal name firm must have an individual Officer title registered in

the category of Telephone number ultimate designated E-mail address person. NRD number, if available

Address Same as firm head office address Address line 1 Address line 2 City Province/territory/state Country Postal/zip code 2.6 Chief compliance officer Same as ultimate designated person A registered Legal name firm must have an individual Officer title registered in

the category of Telephone number chief compliance E-mail address officer. NRD number, if available

Address Same as firm head office address Address line 1 Address line 2

City Province/territory/state Country Postal/zip code Part 3 Business history and structure Business activities 3.1 The firm’s business Provide a description of the firm’s proposed business, including its primary business activities, target market, and the products and services it will provide to clients.

3.2 Other names In addition to the firm’s legal name in question 1.1, does the firm use any other names, such as a trade name?

Yes No If yes, list all other names and indicate if each name has been registered:

3.3 Business documents Does the firm have the following documents to support its business activities? Yes No (a) Business plan for at least the next three years (b) Policies and procedures manual, including account opening procedures and the firm’s policy on fairness in allocation of investment opportunities, if applicable

If no, explain why the firm does not have the document:

Attach the firm’s business plan, policies and procedures manual and client agreements, including any investment policy statements and investment management agreements, except if the regulator in Ontario is the principal regulator of the firm seeking registration, unless the regulator in Ontario has requested they be provided.

History of the firm 3.4 When was the firm created? yyyy/mm/dd

3.5 How was the firm created? New start-up Go to question 3.7.

Merger or amalgamation Go to question 3.6. Reorganization Go to question 3.6. Other statutory arrangement Please specify below and go to question 3.6. 3.6 Predecessors List the entities that were merged, amalgamated, reorganized or otherwise arranged to create the firm.

3.7 Constating documents Attach the legal documents that established the firm as an entity, for example, the firm’s articles and certificate of incorporation, any articles of amendments, partnership agreement or declaration of trust. If the firm is a sole proprietorship, provide a copy of the registration of trade name.

As part of their constating documents, firms whose head office is outside Canada may be required to provide proof of extra-provincial registration.

Business structure and ownership 3.8 Type of legal structure Sole proprietorship Partnership Limited partnership Name of general partner ______________________________ Corporation Other Please specify ______________________________________ 3.9 Business registration number, if applicable This is the List the firm’s business registration number for each jurisdiction of Canada where the firm is seeking firm’s corporate registration. registration number or Business registration number Jurisdiction of Canada Québec enterprise number (NEQ).

3.10 Permitted individuals List all permitted individuals of the firm. Name Title NRD number, if applicable

3.11 Organization chart Attach an organization chart showing the firm’s reporting structure. Include all permitted individuals, the ultimate designated person and the chief compliance officer.

3.12 Ownership chart Attach a chart showing the firm’s structure and ownership. At a minimum, include all parents, specified affiliates and specified subsidiaries.

Include the name of the person or company, and class, type, amount and voting percentage of ownership of the firm’s securities.

Part 4 Registration history The questions in Part 4 apply to any jurisdiction and any foreign jurisdiction. 4.1 Securities registration In the last seven years, has the firm, or any predecessors or specified affiliates of the firm been registered or licensed to trade or advise in securities or derivatives?

Yes No If yes, provide the following information for each registration: Name of entity Registration category Regulator/organization Date registered or licensed (yyyy/mm/dd) Expiry date, if applicable (yyyy/mm/dd) Jurisdiction

4.2 Exemption from securities registration Is the firm currently relying on any exemptions from registration or licensing to trade or advise in securities or derivatives?

Yes No If yes, provide the following information for each exemption: Type of exemption Regulator/organization Date of exemption (yyyy/mm/dd) Jurisdiction 4.3 Membership in an exchange or SRO In the last seven years, has the firm, or any predecessors or specified affiliates of the firm been a member of a securities or derivatives exchange, SRO or similar organization?

Yes No

If yes, provide the following information for each membership: Name of entity Organization Date of membership (yyyy/mm/dd) Expiry date, if applicable (yyyy/mm/dd) Jurisdiction 4.4 Exemption from membership in an exchange or SRO Is the firm currently relying on any exemptions from membership with a securities or derivatives exchange, SRO or similar organization?

Yes No If yes, provide the following information for each exemption: Type of exemption Organization Date of exemption (yyyy/mm/dd) Jurisdiction 4.5 Refusal of registration, licensing or membership Has the firm, or any predecessors or specified affiliates of the firm been refused registration, licensing or membership with a financial services regulator, securities or derivatives exchange, SRO or similar organization?

Yes No If yes, provide the following information for each refusal:

Name of entity Reason for refusal Regulator/organization Date of refusal (yyyy/mm/dd) Jurisdiction 4.6 Registration for other financial products Examples of In the last seven years, has the firm, or any predecessors or specified affiliates of the firm been other financial registered or licensed under legislation that requires registration or licensing to sell or advise in a products financial product other than securities or derivatives? include financial planning, life Yes No insurance and mortgages. If yes, provide the following information for each registration or licence: Name of entity Type of licence or registration

Regulator/organization Date of registration (yyyy/mm/dd) Expiry date, if applicable (yyyy/mm/dd) Jurisdiction Part 5 Financial condition Capital requirements 5.1 Calculation of excess working capital Attach the firm’s calculation of excess working capital. Investment dealers must use the capital calculation form required by the Investment Industry Regulatory Organization of Canada (IIROC).

Mutual fund dealers must use the capital calculation form required by the Mutual Fund Dealers Association of Canada (MFDA), except for mutual fund dealers registered in Québec only.

Firms that are not members of either IIROC or the MFDA must use Form 31-103F1 Calculation of Excess Working Capital. See Schedule C.

5.2 Sources of capital List all cash, cash equivalents, debt and equity sources of the firm’s capital. Name of person or entity providing the capital Type of capital Amount ($) 5.3 Guarantors See Schedule C Form 31- In relation to its business, does the firm: 103F1 Calculation of Excess Yes No Working Capital. (a) Have any guarantors? (b) Act as a guarantor for any party?

If yes, provide the following information for each guarantee: Name of party to the guarantee NRD number, if applicable Relationship to the firm Amount of guarantee ($) Details of the guarantee

Bonding and insurance Questions 5.4 to 5.8 apply to the firm’s bonding or insurance coverage or proposed bonding or insurance coverage for securities and derivatives activities only. This in accordance with Part 12, Division 2 of NI 31-103.

5.4 Jurisdictions covered This information Where does the firm have bonding or insurance coverage? is on the financial AB institution bond. BC MB NB NL NS NT NU ON PE QC SK YT

If the firm’s bonding or insurance does not cover all jurisdictions of Canada where it is seeking registration, explain why.

5.5 Bonding or insurance details This information Name of insurer is on the binder of insurance or on the financial Bond or policy number institution bond. Specific insuring agreements and clauses Coverage for each claim ($) Annual aggregate coverage ($) Total coverage ($) Amount of the deductible ($) Expiry date (yyyy/mm/dd) If the firm’s insurance or proposed insurance is not in the form of a financial institution bond, explain how it provides equivalent coverage to the bond.

5.6 Professional liability insurance (Québec only) This information If the firm is seeking registration in Québec as a mutual fund dealer or a scholarship plan dealer, is required only provide the following information about the firm’s professional liability insurance: if the firm is applying for Name of insurer registration in Québec as a Policy number mutual fund dealer or as a

scholarship Specific insuring agreements and clauses plan dealer.

Coverage for each claim ($) Total coverage ($) Amount of the deductible ($) Jurisdictions covered: AB BC MB NB NL NS Which insurance policy applies to your representatives? Firm's policy Individual's policy 5.7 Directors’ resolution approving insurance Attach a directors’ resolution confirming that the firm has sufficient insurance coverage for its securities or derivatives-related activities.

5.8 Bonding or insurance claims In the last seven years, has the firm made any claims against a bond or on its insurance? Yes No If yes, provide the following information for each claim: Type of bond or insurance Date of claim (yyyy/mm/dd) Amount ($) Reason for claim Date resolved (yyyy/mm/dd) Result Jurisdiction Solvency 5.9 Bankruptcy In the last seven years, has the firm or any of its specified affiliates declared bankruptcy, made an assignment or proposal in bankruptcy, or been the subject of a petition in bankruptcy, or the equivalent in any jurisdiction?

Yes No If yes, provide the following information for each bankruptcy or assignment in bankruptcy: Name of entity Reason for bankruptcy or assignment Date of bankruptcy, assignment or petition Date discharge granted, if applicable

Annual aggregate coverage ($) Renewal date (yyyy/mm/dd) NT NU ON PE QC SK YT Both

(yyyy/mm/dd) (yyyy/mm/dd) Name of trustee Jurisdiction If applicable, attach a copy of any discharge, release or equivalent document. 5.10 Appointment of receiver In the last seven years, has the firm or any of its specified affiliates appointed a receiver or receiver manager, or had one appointed, or the equivalent in any jurisdiction?

Yes No If yes, provide the following information for each appointment of receiver: Name of entity Date of appointment (yyyy/mm/dd) Reason for appointment Date appointment ended (yyyy/mm/dd) Reason appointment ended Name of receiver or receiver manager Jurisdiction Financial reporting 5.11 Financial year-end (mm/dd)

If the firm has not established its financial year-end, explain why. Provide the 5.12 Auditor name of the individual Name of auditor and accounting firm auditing the financial statements and the name of the firm, if applicable.

5.13 Audited financial statements (a) Attach, for your most recently completed year, either (i) non-consolidated audited financial statements; or (ii) audited financial statements prepared in accordance with section 3.2(3) of NI 52-107.

(b) If the audited financial statements attached for item (a) were prepared for a period ending more than 90 days before the date of this application, also attach an interim financial report for a period of not more than 90 days before the date of this application.

If the firm is a start-up company, you can attach an audited opening statement of financial position instead.

5.14 Letter of direction to auditors We may Attach a letter of direction from the firm authorizing the auditor to conduct any audit or request an review of the firm that the regulator may request. audit of the firm at any time while the firm is registered.

Part 6 Client relationships 6.1 Client assets See Part 14, Will the firm hold or have access to client assets? Division 3 of NI 31-103 and Yes No Companion Policy 31- If yes, provide the following information for each financial institution where the trust accounts for client 103CP. assets are held. For guidance Name of financial institution regarding whether a firm Address line 1 will hold or have access to client assets Address line 2 see section 12.4 of City Province/territory Companion Policy 31- Postal code Telephone number 103CP.

6.2 Conflicts of interest Does the firm have or expect to have any relationships that could reasonably result in any significant conflicts of interest in carrying out its registerable activities in accordance with securities or derivatives legislation?

Yes No If yes, complete the following questions: (a) Provide details about each conflict: (b) Does the firm have policies and procedures to identify and respond to its conflicts of interest? Yes No If no, explain why:

Part 7 Regulatory action The questions in Part 7 apply to any jurisdiction and any foreign jurisdiction. The information must be provided in respect of the last 7 years.

7.1 Settlement agreements Has the firm, or any predecessors or specified affiliates of the firm entered into a settlement agreement with any financial services regulator, securities or derivatives exchange, SRO or similar organization?

Yes No If yes, provide the following information for each settlement agreement: Name of entity Regulator/organization Date of settlement (yyyy/mm/dd) Details of settlement Jurisdiction

7.2 Disciplinary history Has any financial services regulator, securities or derivatives exchange, SRO or similar organization: Yes No Determined that the firm, or any predecessors or specified affiliates of the firm violated any securities regulations or any rules of a securities or derivatives exchange, SRO or similar organization?

Determined that the firm, or any predecessors or specified affiliates of the firm made a false statement or omission?

Issued a warning or requested an undertaking by the firm, or any predecessors or specified affiliates of the firm?

Suspended or terminated any registration, licensing or membership of the firm, or any predecessors or specified affiliates of the firm?

Imposed terms or conditions on any registration or membership of the firm, or predecessors or specified affiliates of the firm?

Conducted a proceeding or investigation involving the firm, or any predecessors or specified affiliates of the firm?

Issued an order (other than an exemption order) or a sanction to the firm, or any predecessors or specified affiliates of the firm for securities or derivatives-related activity (e.g. cease trade order)?

If yes, provide the following information for each action: Name of entity Type of action Regulator/organization Date of action (yyyy/mm/dd) Reason for action Jurisdiction

7.3 Ongoing investigations Is the firm aware of any ongoing investigations of which the firm or any of its specified affiliates is the subject?

Yes No If yes, provide the following information for each investigation: Name of entity Reason or purpose of investigation Regulator/organization Date investigation commenced (yyyy/mm/dd) Jurisdiction Part 8 Legal action The firm must disclose offences or legal actions under any statute governing the firm and its business activities in any jurisdiction. The information must be provided in respect of the last 7 years.

8.1 Criminal convictions Has the firm, or any predecessors or specified affiliates of the firm been convicted of any criminal or quasi-criminal offence?

Yes No If yes, provide the following information for each conviction: Name of entity Type of offence Case name Case number, if applicable Date of conviction (yyyy/mm/dd) Jurisdiction

8.2 Outstanding criminal charges Is the firm or any of its specified affiliates currently the subject of any outstanding criminal or quasi-criminal charges?

Yes No If yes, provide the following information for each charge: Name of entity

Type of offence Date of charge (yyyy/mm/dd) Jurisdiction 8.3 Outstanding legal actions Yes No (a) Is the firm currently a defendant or respondent (or the equivalent in any jurisdiction) in any outstanding legal action?

(b) Are any of the firm’s specified affiliates currently a defendant or respondent (or the equivalent in any jurisdiction) in any outstanding legal action that involves fraud, theft or securities-related activities, or that could significantly affect the firm’s business?

If yes, provide the following information for each legal action: Name of entity Type of legal action Date of legal action (yyyy/mm/dd) Current stage of litigation Remedies requested by plaintiff or appellant Jurisdiction 8.4 Judgments Yes No Has any judgment been rendered against the firm or is any judgment outstanding in any civil court for damages or other relief relating to fraud, theft or securities-related activities?

Are any of the firm’s specified affiliates currently the subject of any judgments that involve fraud, theft or securities-related activities, or that could significantly affect the firm’s business?

If yes, provide the following information for each judgment: Name of entity Type of judgment Date of judgment (yyyy/mm/dd) Current stage of litigation, if applicable Remedies requested by plaintiffs Part 9 Certification

It is an offence under securities legislation and derivatives legislation, including commodity futures legislation, to give false or misleading information on this form.

By signing below, you: 1. Certify to the regulator in each jurisdiction of Canada where the firm is submitting and filing this form, either directly or through the principal regulator, that: you have read this form, and to the best of your knowledge and after reasonable inquiry, all of the information provided on this form is true and complete.

2. Certify to each regulator in a non-principal jurisdiction of Canada where the firm is submitting and filing this form, either directly or through the principal regulator, that at the date of this submission: the firm has submitted and filed all information required to be submitted and filed under the securities legislation or derivatives legislation or both of the principal jurisdiction of Canada in relation to the firm’s registration in that jurisdiction, and this information is true and complete. 3. Authorize the principal regulator to give each non-principal regulator access to any information the firm has submitted or filed with the principal regulator under securities legislation or derivatives legislation or both of the principal jurisdiction of Canada in relation to the firm’s registration in that jurisdiction.

4. Acknowledge that the regulator may collect and provide personal information about the individuals referred to in this form under Collection and use of personal information.

5. Confirm that the individuals referred to in this form have been notified that their personal information is disclosed on this form, the legal reason for doing so, how it will be used and who to contact for more information.

Name of firm Name of firm’s authorized signing officer or partner Title of firm’s authorized signing officer or partner Signature Date (yyyy/mm/dd)

Witness The witness Name of witness must be a lawyer, notary public or Title of witness commissioner of oaths. Signature Date (yyyy/mm/dd)

Schedule A Contact information for Notice of collection and use of personal information

Alberta Alberta Securities Commission Suite 600, 250–5th St. SW Calgary, AB T2P 0R4 Attention: Information Officer Telephone: (403) 297-6454

British Columbia British Columbia Securities Commission P.O. Box 10142, Pacific Centre 701 West Georgia Street Vancouver, BC V7Y 1L2 Attention: Freedom of Information Officer Telephone: (604) 899-6500 or (800) 373-6393 (in Canada)

Manitoba The Manitoba Securities Commission 500 - 400 St. Mary Avenue Winnipeg, MB R3C 4K5 Attention: Director of Registrations Telephone: (204) 945-2548 Fax: (204) 945-0330 New Brunswick Financial and Consumer Services Commission of New Brunswick / Commission des services financiers et des services aux consommateurs du Nouveau-Brunswick Suite 300, 85 Charlotte Street Saint John, NB E2L 2J2 Attention: Director of Securities Telephone: (506) 658-3060

Newfoundland and Labrador Superintendent of Securities, Service NL Government of Newfoundland and Labrador P.O. Box 8700 2nd Floor, West Block Confederation Building St. John's, NL A1B 4J6 Attention: Manager of Registrations Telephone: (709) 729-5661

Nova Scotia Nova Scotia Securities Commission Suite 400, 5251 Duke Street Halifax, NS B3J 1P3 Attention: Deputy Director, Capital Markets Telephone: (902) 424-7768

Northwest Territories Government of the Northwest Territories Department of Justice 1 st Floor Stuart M. Hodgson Building 5009 49 th Street Yellowknife, NWT X1A 2L9 Attention: Deputy Superintendent of Securities Telephone: (867) 920-8984

Nunavut Government of Nunavut Department of Justice P.O. Box 1000 Station 570 Iqaluit, NU X0A 0H0 Attention: Deputy Registrar of Securities Telephone: (867) 975-6590

Ontario Ontario Securities Commission 22 nd Floor 20 Queen Street West Toronto, ON M5H 3S8 Attention: Compliance and Registrant Regulation Telephone: (416) 593-8314 e-mail: registration@osc.gov.on.ca

Prince Edward Island Securities Office Department of Community Affairs and Attorney General P.O. Box 2000 Charlottetown, PE C1A 7N8 Attention: Deputy Registrar of Securities Telephone: (902) 368-6288 Québec Autorité des marchés financiers 800, square Victoria, 22e étage C.P. 246, tour de la Bourse Montréal (Québec) H4Z 1G3 Attention: Responsable de l’accès à l’information Telephone: (514) 395-0337 or (877) 525-0337

Saskatchewan Financial and Consumer Affairs Authority of Saskatchewan Suite 601, 1919 Saskatchewan Drive Regina, SK S4P 4H2 Attention: Deputy Director, Capital Markets Telephone: (306) 787-5871

Yukon Government of Yukon Superintendent of Securities Department of Community Services P.O. Box 2703 C-6 Whitehorse, YT Y1A 2C6 Attention: Superintendent of Securities Telephone: (867) 667-5314

Self-regulatory organization Investment Industry Regulatory Organization of Canada 121 King Street West, Suite 2000 Toronto, Ontario M5H 3T9 Attention: Privacy Officer Telephone: (416) 364-6133 E-mail: PrivacyOfficer@iiroc.ca

Schedule B Submission to jurisdiction and appointment of agent for service

1. Name of person or company (the “Firm”): _____________________________________________________ 2. Jurisdiction of incorporation of the person or company: __________________________________________ 3. Name of agent for service of process (the "Agent for Service"): ___________________________________ 4. Address for service of process on the Agent for Service: _________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Phone number of the Agent for Service: ___________________________________________________ 5. The Firm designates and appoints the Agent for Service at the address stated above as its agent upon whom may be served a notice, pleading, subpoena, summons or other process in any action, investigation or administrative, criminal, quasi-criminal or other proceeding (a "Proceeding") arising out of or relating to or concerning the Firm's activities in the local jurisdiction and irrevocably waives any right to raise as a defense in any such proceeding any alleged lack of jurisdiction to bring such Proceeding.

6. The Firm irrevocably and unconditionally submits to the non-exclusive jurisdiction of the judicial, quasi-judicial and administrative tribunals of the local jurisdiction and any administrative proceeding in the local jurisdiction, in any proceeding arising out of or related to or concerning the Firm's activities in the local jurisdiction.

7. Until six years after the Firm ceases to be registered, the Firm must file a. a new Submission to jurisdiction and appointment of agent for service in this form no later than the 10th day after the date this Submission to jurisdiction and appointment of agent for service is terminated; and

b. an amended Submission to jurisdiction and appointment of agent for service no later than the 10th day after any change in the name or above address of the Agent for Service.

8. This Submission to jurisdiction and appointment of agent for service is governed by and construed in accordance with the laws of the local jurisdiction.

Dated: ____________________________________ __________________________________________ (Signature of the Firm or authorized signatory)

__________________________________________ (Name and Title of authorized signatory)

Acceptance The undersigned accepts the appointment as Agent for Service of (Insert name of the Firm) under the terms and conditions of the foregoing Submission to jurisdiction and appointment of agent for service.

Dated: ____________________________________ __________________________________________ (Signature of Agent for Service or authorized signatory)

__________________________________________ (Name and Title of authorized signatory)

Schedule C FORM 31-103F1 CALCULATION OF EXCESS WORKING CAPITAL

______________________________________ Firm Name

Capital Calculation (as at ________________ with comparative figures as at ______________)

Component Current period Prior period 1. Current assets 2. Less current assets not readily convertible into cash (e.g., prepaid expenses)

3. Adjusted current assets Line 1 minus line 2 =

4. Current liabilities 5. Add 100% of non-current related party debt unless the firm and the lender have executed a subordination agreement in the form set out in Appendix B of National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations and the firm has delivered a copy of the agreement to the regulator or, in Québec, the securities regulatory authority. See section 12.2 of National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations.

6. Adjusted current liabilities Line 4 plus line 5 =

7. Adjusted working capital Line 3 minus line 6 =

8. Less minimum capital 9. Less market risk 10. Less any deductible under the bonding or insurance policy required under Part 12 of National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations

11. Less Guarantees 12. Less unresolved differences 13. Excess working capital

Notes: Form 31-103F1 Calculation of Excess Working Capital must be prepared using the accounting principles that you use to prepare your financial statements in accordance with National Instrument 52-107 Acceptable Accounting Principles and Auditing Standards. Section 12.1 of Companion Policy 31-103CP Registration Requirements, Exemptions and Ongoing Registrant Obligations provides further guidance in respect of these accounting principles.

Line 5. Related-party debt Refer to the CICA Handbook for the definition of “related party” for publicly accountable enterprises. The firm is required to deliver a copy of the executed subordination agreement to the regulator or, in Québec, the securities regulatory authority on the earlier of a) 10 days after the date the agreement is executed or b) the date an amount subordinated by the agreement is excluded from its calculation of excess working capital on Form 31-103F1 Calculation of Excess Working Capital. The firm must notify the regulator or, in Québec, the securities regulatory authority, 10 days before it repays the loan (in whole or in part), or terminates the subordination agreement. See section 12.2 of National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations.

Line 8. Minimum Capital The amount on this line must be not less than (a) $25,000 for an adviser and (b) $50,000 for a dealer. For an investment fund manager, the amount must be not less than $100,000 unless subsection 12.1(4) of National Instrument 31-103 Registration Requirements, Exemptions and Ongoing Registrant Obligations applies.

Line 9. Market Risk The amount on this line must be calculated according to the instructions set out in Schedule 1 to Form 31-103F1 Calculation of Excess Working Capital. A schedule supporting the calculation of any amounts included in Line 9 as market risk should be provided to the regulator or, in Québec, the securities regulatory authority in conjunction with the submission of Form 31-103F1 Calculation of Excess Working Capital.

Line 11. Guarantees If the registered firm is guaranteeing the liability of another party, the total amount of the guarantee must be included in the capital calculation. If the amount of a guarantee is included in the firm’s statement of financial position as a current liability and is reflected in line 4, do not include the amount of the guarantee on line 11.

Line 12. Unresolved differences Any unresolved differences that could result in a loss from either firm or client assets must be included in the capital calculation. The examples below provide guidance as to how to calculate unresolved differences:

(i) If there is an unresolved difference relating to client securities, the amount to be reported on Line 12 will be equal to the fair value of the client securities that are short, plus the applicable margin rate for those securities.

(ii) If there is an unresolved difference relating to the registrant's investments, the amount to be reported on Line 12 will be equal to the fair value of the investments (securities) that are short.

(iii) If there is an unresolved difference relating to cash, the amount to be reported on Line 12 will be equal to the amount of the shortfall in cash.

Please refer to section 12.1 of Companion Policy 31-103CP Registration Requirements, Exemptions and Ongoing Registrant Obligations for further guidance on how to prepare and file Form 31-103F1 Calculation of Excess Working Capital.

Management Certification Registered Firm Name: ___________________________________________ We have examined the attached capital calculation and certify that the firm is in compliance with the capital requirements as at ______________________________. Name and Title Signature Date 1. ______________________ _________________________ ________________________ _______________________ 2. ______________________ _________________________ ________________________ _______________________

Schedule 1 of Form 31-103F1 Calculation of Excess Working Capital (calculating line 9 [market risk])

For purposes of completing this form: (1) “Fair value” means the value of a security determined in accordance with Canadian GAAP applicable to publicly accountable enterprises.

(2) For each security whose value is included in line 1, Current Assets, multiply the fair value of the security by the margin rate for that security set out below. Add up the resulting amounts for all of the securities you hold. The total is the "market risk" to be entered on line 9.

(a) Bonds, Debentures, Treasury Bills and Notes (i) Bonds, debentures, treasury bills and other securities of or guaranteed by the Government of Canada, of the United Kingdom, of the United States of America and of any other national foreign government (provided such foreign government securities are currently rated Aaa or AAA by Moody's Canada Inc. or its DRO affiliate or Standard & Poor's Rating Services (Canada) or its DRO affiliate, respectively), maturing (or called for redemption):

within 1 year: 1% of fair value multiplied by the fraction determined by dividing the number of days to maturity by 365

over 1 year to 3 years: 1 % of fair value over 3 years to 7 years: 2% of fair value over 7 years to 11 years: 4% of fair value over 11 years: 4% of fair value (ii) Bonds, debentures, treasury bills and other securities of or guaranteed by any jurisdiction of Canada and obligations of the International Bank for Reconstruction and Development, maturing (or called for redemption):

within 1 year: 2% of fair value multiplied by the fraction determined by dividing the number of days to maturity by 365

over 1 year to 3 years: 3 % of fair value over 3 years to 7 years: 4% of fair value over 7 years to 11 years: 5% of fair value over 11 years: 5% of fair value (iii) Bonds, debentures or notes (not in default) of or guaranteed by any municipal corporation in Canada or the United Kingdom maturing:

within 1 year: 3% of fair value multiplied by the fraction determined by dividing the number of days to maturity by 365

over 1 year to 3 years: 5 % of fair value over 3 years to 7 years: 5% of fair value over 7 years to 11 years: 5% of fair value over 11 years: 5% of fair value (iv) Other non-commercial bonds and debentures (not in default): 10% of fair value (v) Commercial and corporate bonds, debentures and notes (not in default) and non-negotiable and non-transferable trust company and mortgage loan company obligations registered in the registered firm’s name maturing:

within 1 year: 3% of fair value over 1 year to 3 years: 6 % of fair value over 3 years to 7 years: 7% of fair value over 7 years to 11 years: 10% of fair value over 11 years: 10% of fair value (b) Bank Paper

Deposit certificates, promissory notes or debentures issued by a Canadian chartered bank (and of Canadian chartered bank acceptances) maturing:

within 1 year: 2% of fair value multiplied by the fraction determined by dividing the number of days to maturity by 365

over 1 year: apply rates for commercial and corporate bonds, debentures and notes (c) Acceptable foreign bank paper Deposit certificates, promissory notes or debentures issued by a foreign bank, readily negotiable and transferable and maturing: within 1 year: 2% of fair value multiplied by the fraction determined by dividing the number of days to maturity by 365

over 1 year: apply rates for commercial and corporate bonds, debentures and notes “Acceptable Foreign Bank Paper” consists of deposit certificates or promissory notes issued by a bank other than a Canadian chartered bank with a net worth (i.e., capital plus reserves) of not less than $200,000,000.

(d) Mutual Funds Securities of mutual funds qualified by prospectus for sale in any jurisdiction of Canada: (i) 5% of the net asset value per security as determined in accordance with National Instrument 81-106 Investment Fund Continuous Disclosure, where the fund is a money market mutual fund as defined in National Instrument 81-102 Investment Funds; or

(ii) the margin rate determined on the same basis as for listed stocks multiplied by the net asset value per security of the fund as determined in accordance with National Instrument 81-106 Investment Fund Continuous Disclosure.

Securities of mutual funds qualified by prospectus for sale in the United States of America: 5% of the net asset value per security if the fund is registered as an investment company under the Investment Companies Act of 1940, as amended from time to time, and complies with Rule 2a-7 thereof.

(e) Stocks In this paragraph, “securities” includes rights and warrants and does not include bonds and debentures. (i) On securities including investment fund securities, rights and warrants, listed on any exchange in Canada or the United States of America:

Long Positions Margin Required Securities selling at $2.00 or more 50% of fair value Securities selling at $1.75 to $1.99 60% of fair value Securities selling at $1.50 to $1.74 80% of fair value Securities