Form U6 (For CRD Individual) {U6}

Rev. FORM U6 (06/2003) INDIVIDUAL NAME: INDIVIDUAL CRD #: U6 - SUBJECT OF ACTION FIRST NAME: SUFFIX: DOB (MM/DD/YYYY): RESIDENTIAL STREET ADDRESS LINE 1: CITY: STATE: MIDDLE NAME: ALIAS: SSN: CRD #: RESIDENTIAL STREET ADDRESS LINE 2: COUNTRY: ZIP/POSTAL CODE: LAST NAME: SSN: RESIDENTIAL STREET ADDRESS LINE 1: CITY: STATE: RESIDENTIAL STREET ADDRESS LINE 2: COUNTRY: ZIP/POSTAL CODE: BUSINESS STREET ADDRESS LINE 1: CITY: REGULATOR CONTACT: STATE: BUSINESS STREET ADDRESS LINE 2: COUNTRY: REGULATOR PHONE NUMBER: ZIP/POSTAL CODE: Page 1 of 8 American LegalNet, Inc. www.FormsWorkflow.com Rev. FORM U6 (06/2003) INDIVIDUAL NAME: INDIVIDUAL CRD #: SSN: DISCLOSURE REPORTING PAGES U6 - BANKRUPTCY/SIPC/COMPROMISE WITH CREDITORS DRP This Disclosure Reporting Page is an 1. INITIAL OR AMENDED Action Type: [Circle one: Bankruptcy, Compromise, Declaration, Liquidated, Other, Receivership] 2. Action Date (MM/DD/YYYY) (Provide date bankruptcy was filed, or date SIPC was initiated, or date of compromise with creditor): ___________________ Explanation Exact If not exact, provide explanation: 3. If the financial action relates to an organization over which the subject exercise(d) control, enter Organization Name and subject's position, title or relationship: Was the Organization investment-related? Yes No 4. Court (Name of Federal, State or Foreign Court), Location of Court (City or County and State or Country), Docket/Case Number and Bankruptcy Chapter Number (if Federal Bankruptcy Filing): 5. Is action currently pending? 6. 7. Yes No If not pending, provide disposition type: [Circle one: Direct Payment Procedure, Discharged, Dismissed, Dissolved, Other, SIPA Trustee Appointed, Satisfied/Released] Disposition Date (MM/DD/YYYY): __________________ If not exact, provide explanation: Exact Explanation 8. Provide a brief summary of events leading to the action and if not discharged, explain. (The information must fit within the space provided.): 9. If a SIPA trustee was appointed or a direct payment procedure was begun, enter the amount paid or agreed to be paid by the subject; or the name of the trustee: Currently Open? Yes No Date Direct Payment Initiated/Filed or Trustee Appointed (MM/DD/YYYY): _______________ Exact Explanation If not exact, provide explanation: 10. Comment (Optional). You may use this field to provide a brief summary of the circumstances leading to the action as well as the current status or final disposition. Your information must fit within the space provided. Page 2 of 8 American LegalNet, Inc. www.FormsWorkflow.com Rev. FORM U6 (06/2003) INDIVIDUAL NAME: INDIVIDUAL CRD #: U6 - CIVIL JUDICIAL DRP This Disclosure Reporting Page is an INITIAL OR AMENDED SSN: 1. Court Action initiated by: (Name of regulator, foreign financial regulatory authority, SRO, commodities exchange, Agency, Firm, Private Plaintiff, etc.) 2. Principal Relief Sought: [Circle one: Cease and Desist, Civil Penalty(ies)/Fine(s), Disgorgement, Injunction, Money Damages (Private/Civil Complaint), Other, Restitution, Restraining Order] Other Relief Sought: 3. Filing Date of Court Action (MM/DD/YYYY): ____________________ If not exact, provide explanation: Exact Explanation 4. Principal Product Type: [Circle one: Annuity(ies) - Fixed, Annuity(ies) - Variable, Banking Products (Other than CD(s)), CD(s), Commodity Options(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 Options(s), Insurance, Investment Contract(s), Money Market Fund(s), Mutual Fund(s), No Product, Options, Other, Penny Stock(s), Unit Investment Trust(s)] Other Product Types: 5. Formal Action was brought in (include name of Federal, Military, State or Foreign Court, Location of Court - City or County and State or Country, Docket/Case Number): 6. Employing Firm when activity occurred which led to the civil judicial action: ____________________________ 7. Describe the allegations related to this civil action. (The information must fit within the space provided.): 8. Current Status? Pending On Appeal Final 9. If on appeal, action appealed to (provide name of court): Date Appeal Filed (MM/DD/YYYY): ______________ Page 3 of 8 American LegalNet, Inc. www.FormsWorkflow.com Rev. FORM U6 (06/2003) INDIVIDUAL NAME: INDIVIDUAL CRD #: SSN: U6 - CIVIL JUDICIAL DRP (CONTINUED) 10. If pending, date notice/process was served (MM/DD/YYYY): __________________ If not exact, provide explanation: Exact Explanation If Final or On Appeal, complete all items below. For Pending Actions, complete Item 14 only. 11. How was matter resolved: [Circle one: Consent, Dismissed, Judgment Rendered, Opinion, Other, Settled, Withdrawn] 12. Resolution Date (MM/DD/YYYY): ____________________ If not exact, provide explanation: Exact Explanation 13. Resolution Detail: A. Were any of the following Sanctions Ordered or Relief Granted? (Check all appropriate items): Monetary/Fine Amount: $_____________ Revocation/Expulsion/Denial Censure Bar Disgorgement/Restitution Cease and Desist/Injunction Suspension B. Other Sanctions: 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 broker, date paid and if any portion of penalty was waived: 14. Comment (Optional). You may use this field to provide a brief summary of the circumstances leading to the action, as well as the current status or disposition and/or finding(s). Include the number of investors in the reporting jurisdiction, the total number of investors in the program, the amount invested in the reporting jurisdiction, and the total amount invested. Your information must fit within the space provided. Page 4 of 8 American LegalNet, Inc. www.FormsWorkflow.com Rev. FORM U6 (06/2003) INDIVIDUAL NAME: INDIVIDUAL CRD #: U6 - CRIMINAL DRP This Disclosure Reporting Page is an 1. INITIAL OR AMENDED SSN: If charge(s) were brought against an organization over which the subject exercise(d) control: (Enter Org