Supplemental Broker Dealer Statement {M-3}

File No. N.Y. Form M-3(Rev. /) (Found on fee receipt for original filing.)STATE OF NEW YORK DEPARTMENT OF LAW BUREAU SUPPLEMENTAL BROKER DEALERSTATEMENT Firm Name Principal OfficeStreet AddressPhone No. CityStateZipA securities broker or dealer shall, not later than 30 days after occurrence, complete this statement. All changes occurring within30 days can be filed on one M-3 (with attachments if necessary). Attach additional sheets if space provided is inadequate. Youmay submit a photocopy of the form to be return with your fee receipt as an acknowledgment of registration.1. Change of securities salesperson. (Not for member firms who must file a U-4 with the CentralRegistrationDepository.)A. NEW SALESPERSONS EMPLOYED. A Salesperson Statement (Form M-2) or Supplemental Salesperson Statement (Form M-4) for each new employee must accompany this form.DateNameAddressB. SALESPERSONS TERMINATED.DateNameAddressReason for Termination2.CHANGE IN FIRM NAME OR ADDRESS OR BRANCH OFFICE. DateFrom: To: 3.TERMINATION OR WITHDRAWAL OF DEALERSHIP AS OF DATE.Reason:4. Change in officers, directors or other principals. The information set forth below must be provided for each officer,director, principal or partner. For a corporate partner, information must be provided for all officers of the corporategeneral partner. If the change is termination of an officer, only the first three lines need to be completed.Name:Date of Change: Nature of Change:Home Address:Phone No.: Social Security No.:Date of Birth: Place of Birth: American LegalNet, Inc. www.FormsWorkFlow.com A. been suspended or expelled from membership in any securities or commodities exchange, association of securities or commodities dealers or investment advisors?....Yes [ ] No [ ] B. had a license or registration as a dealer, broker, investment advisor or salesperson, futures commission merchant, associated person, commodity pool operator, or commodity trading advisor denied, suspended or revoked?.......................................Yes [ ] No [ ]C. been enjoined or restrained by any court or agency from:1.the issuance, sale or offer for sale of securities or commodities?.........................Yes [ ] No [ ]2.rendering securities or commodities advice?........................................................Yes [ ] No [ ]3.handling or managing trading account?................................................................Yes [ ] No [ ]4.continuing any practices in connection with securities or commodities?.............Yes [ ] No [ ]D. been convicted of any crime (other than minor traffic violation)?............................Yes [ ] No [ ]E. used or been known by any other name?...................................................................Yes [ ] No [ ]F. been the subject of any professional disciplinary proceeding?..................................Yes [ ] No [ ]G. been adjudged a bankrupt or made a general assignment for benefit of creditors; or been an officer, director or principal of any entity which was reorganized in bankruptcy, adjudged a bankrupt or made a general assignment for benefit of creditors?....................................................................................................................Yes [ ] No [ ]H. had an offering of securities within the last three years or been an officer, director, principal or partner of any entity which had an offering of securities within the last three years?...................................................................................................................Yes [ ] No [ ]If the answer to any of the above is 223yes,224 explain and attach a copy of the judgement, order, etc. if one exists.6.Are there any outstanding judgements (not including judgements involving domesticrelations) against the issuer or any officer, director, principal or partner thereof?If yes, explain...................................................................................................................Yes [ ] No [ ]I hereby represent that all statements contained herein are true and that I fully understand that any false statements constitutes aviolation of Article 23-A of the General Business Law.Dated Signature (Individual proprietor, partner, or principal officer of corporation, trust or association.) A fee of $30 must accompany this form. Submit a money order or company, bank or attorney222s check payable to the N.Y.S.Department of Law. Remit to: N.Y.S. Department of Law, Bureau Floor, New York, NY 10 American LegalNet, Inc. www.FormsWorkFlow.com