The application for a certificate as an investment adviser and all amendments thereto shall be filed as follows:
STATE OF CALIFORNIA DEPARTMENT OF BUSINESS OVERSIGHT CUSTOMER AUTHORIZATION OF DISCLOSURE OF FINANCIAL RECORDS
Pursuant to Corporations Code Section 25241 and Government Code Sections 7470 and 7473, any financial institution, wherever situated, possessing financial records of:
___________________________
Name of (check appropriate designation(s) below)
__________ Broker-Dealer
__________ Investment Adviser
is hereby authorized to disclose to the California Department of Business Oversight records of the above named broker-dealer or investment adviser business whether such records relate to accounts which have been closed, accounts which are currently maintained, or accounts which are hereafter established.
This authorization is effective as of the date of execution and shall remain effective until five years after the expiration or revocation of the above-named broker-dealer or investment adviser license, including renewals of such license.
This authorization may not be revoked.
The terms used in this authorization shall have the definitions contained in the California Right to Financial Privacy Act (Government Code Section 7460 et seq.) and the Corporate Securities Law (Corporations Code Section 25000 et seq.).
The above-named licensee has duly caused this authorization to be signed on its behalf by the undersigned, thereunto duly authorized. Executed on ______________________________, 20 ___ at _______________
____________________
Name of Licensee
______________________________
Licensee's Department of
Business Oversight File Number
By ________________________________________
________________________________________
(Title)
Form QR 500.261
STATE OF CALIFORNIA DEPARTMENT OF BUSINESS OVERSIGHT
INSTRUCTIONS FOR CUSTOMER AUTHORIZATION OF DISCLOSURE OF FINANCIAL RECORDS
On the reverse is a Customer Authorization of Disclosure of Financial Records form. The Commissioner of Business Oversight is authorized to require such authorization from certain licensees and other persons pursuant to the authority cited in the first paragraph of the form.
The form must be properly executed and submitted with the attached application for license, qualification, registration or other authority.
All information required on the form, except the signature of the person executing the form, is to be typewritten.
If the form requests a Department of Business Oversight file number, the applicant need only provide such number if it is known to the applicant and is the type of file number appropriate for the license, qualification, registration or other authority applied for in the attached application.
If additional authorization forms are needed, they may be obtained from any office of the Department of Business Oversight, or accurate copies of the form may be utilized by applicants.
NOTICES REQUIRED UNDER STATE AND FEDERAL LAW INFORMATION PRACTICES ACT OF 1977 (California Civil Code Section 1798.17)
FEDERAL PRIVACY ACT OF 1974 (Public Law 93-579)
In accordance with Section 7 of the Privacy Act of 1974 (found at 5 U.S.C. § 552a note (Disclosure of Social Security Number)), the following is information on whether the disclosure of a social security account number is voluntary or mandatory, by what statutory or other authority such number is solicited, and what uses will be made of it.
NOTICE REGARDING TAXPAYER INFORMATION
Cal. Code Regs. Tit. 10, § 260.231
2. Amendment filed 7-13-70; effective thirtieth day thereafter (Register 70, No. 29).
3. Amendment filed 3-1-74; effective thirtieth day thereafter (Register 74, No. 9).
4. Amendment of form (Item 6-A) filed 7-18-79; effective thirtieth day thereafter (Register 79, No. 29).
5. Amendment filed 4-27-84; effective thirtieth day thereafter (Register 84, No. 18).
6. Repealer and new section filed 12-19-85 as an emergency; designated effective 1-1-86 (Register 85, No. 51). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 5-1-86.
7. Editorial correction of Part III (2) printing error (Register 86, No. 5).
8. Certificate of Compliance as to 12-19-85 order transmitted to OAL 4-10-86 and filed 5-8-86 (Register 86, No. 19).
9. Change without regulatory effect filed 3-2-89 (Register 89, No. 11).
10. Change without regulatory effect amending first paragraph of Part I and Part III(1) filed 11-20-91 pursuant to section 100, title 1, California Code of Regulations (Register 92, No. 9).
11. Change without regulatory effect amending subsection (b) filed 2-16-95 pursuant to section 100, title 1, California Code of Regulations (Register 95, No. 7).
12. Change without regulatory effect amending subsection (b) filed 9-25-2002 pursuant to section 100, title 1, California Code of Regulations (Register 2002, No. 39).
13. Repealer and new section filed 3-4-2003; operative 4-3-2003 (Register 2003, No. 10).
14. Amendment of section and NOTE filed 3-6-2007; operative 4-5-2007 (Register 2007, No. 10).
15. Amendment of subsections (a)(3), (i) and (j) and amendment of NOTE filed 1-7-2014; operative 1-7-2014 pursuant to Government Code section 11343.4(b)(3) (Register 2014, No. 2).
Note: Authority cited Sections 25231, 25610, 25612.3 and 25612.5, Corporations Code. Reference: Sections 31 and 494.5, Business and Professions Code; Section 1798.17, Civil Code; Sections 25230, 25231, 25234, 25236, 25237, 25241, 25242, 25608, 25612.3, 25612.5 and 25613, Corporations Code; Section 17520, Family Code; Sections 7470, 7473, 7490 and 13140- 13144, Government Code; and Section 7 of Public Law 93-579(5 U.S.C. Section 552a note).
2. Amendment filed 7-13-70; effective thirtieth day thereafter (Register 70, No. 29).
3. Amendment filed 3-1-74; effective thirtieth day thereafter (Register 74, No. 9).
4. Amendment of form (Item 6-A) filed 7-18-79; effective thirtieth day thereafter (Register 79, No. 29).
5. Amendment filed 4-27-84; effective thirtieth day thereafter (Register 84, No. 18).
6. Repealer and new section filed 12-19-85 as an emergency; designated effective 1-1-86 (Register 85, No. 51). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 5-1-86.
7. Editorial correction of Part III (2) printing error (Register 86, No. 5).
8. Certificate of Compliance as to 12-19-85 order transmitted to OAL 4-10-86 and filed 5-8-86 (Register 86, No. 19).
9. Change without regulatory effect filed 3-2-89 (Register 89, No. 11).
10. Change without regulatory effect amending first paragraph of Part I and Part III(1) filed 11-20-91 pursuant to section 100, title 1, California Code of Regulations (Register 92, No. 9).
11. Change without regulatory effect amending subsection (b) filed 2-16-95 pursuant to section 100, title 1, California Code of Regulations (Register 95, No. 7).
12. Change without regulatory effect amending subsection (b) filed 9-25-2002 pursuant to section 100, title 1, California Code of Regulations (Register 2002, No. 39).
13. Repealer and new section filed 3-4-2003; operative 4-3-2003 (Register 2003, No. 10).
14. Amendment of section and Note filed 3-6-2007; operative 4-5-2007 (Register 2007, No. 10).
15. Amendment of subsections (a)(3), (i) and (j) and amendment of Note filed 1-7-2014; operative 1-7-2014 pursuant to Government Code section 11343.4(b)(3) (Register 2014, No. 2).