UNITED STATES 

SECURITIES AND EXCHANGE COMMISSION 

Washington, D.C. 20549 

FORM ADV-E 

OMB APPROVAL 

OMB Number: 3235-0361 

Expires: February 28, 2025 

Estimated average burden hours 

per response . . . . . . . . . . . . . . .0.05 

Certificate of Accounting of Client Securities and Funds in the Possession or Custody of an Investment Adviser 

Pursuant to Rule 206(4)-2 [17 CFR 275.206(4)-2] 

1. Investment Adviser Act SEC File Number: 

801-

Date examination completed: 

2. State Identification Number: 

AL AK AZ AR 

CO CT DE DC 

GA HI ID IL 

IA KS KY LA 

MD MA MI MN 

MO MT NE NV 

NJ NM NY NC 

OH OK OR PA 

SC SD TN TX 

VT VI VA WA 

WI WY PUERTO RICO Other (specify): 

CA 

FL 

IN 

ME 

MS 

NH 

ND 

RI 

UT 

WV 

3. Full name of investment adviser (if individual, state last, first, middle name): 

4. Name under which business is conducted, if different from above: 

5. Address of principal place of business (number, street, city, state, zip code): 

INSTRUCTIONS 

This Form must be completed by investment advisers that have custody of client funds or securities and that are subject to an annual surprise 

examination. This Form may not be used to amend any information included in an investment adviser’s registration statement (e.g., business address).

Investment Adviser 

1. All items must be completed by the investment adviser. 

2. Give this Form to the independent public accountant that, in compliance with rule 206(4)-2 under the Investment Advisers Act of 1940 (the “Act”)

or applicable state law, examines client funds and securities in the custody of the investment adviser within 120 days of the time chosen by the 

accountant for the surprise examination and upon such accountant’s resignation or dismissal from, or other termination of, the engagement, or if 

the accountant removes itself or is removed from consideration for being reappointed. 

Accountant 

3. The independent public accountant performing the surprise examination must submit electronically on the Investment Adviser Registration 

Depository: 

(i) this Form and a certificate of accounting (i.e., accountant’s report) required by rule 206(4)-2 under the Act or applicable state law within 120 

days of the time chosen by the accountant for the surprise examination, and 

(ii) this Form and a statement, within four business days of its resignation or dismissal from, or other termination of, the engagement, or removing 

itself or being removed from consideration for being reappointed, that includes 

(A) the date of such resignation, dismissal, removal, or other termination, and the name, address, and contact information of the accountant, 

and 

(B) an explanation of any problems relating to examination scope or procedure that contributed to such resignation, dismissal, removal, or 

other termination: 

THIS FORM MUST BE GIVEN TO YOUR INDEPENDENT PUBLIC ACCOUNTANT 

SEC’S COLLECTION OF INFORMATION. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information 

unless it displays a currently valid control number. Sections 203(c)(1) and 204 of the Advisers Act authorize the Commission to collect the information 

on this Form from applicants. See 15 U.S.C. §§ 80b-3(c)(1) and 80b-4. Filing of this Form is mandatory. The principal purpose of this collection of 

SEC 2223 (01-13) 
 

 

 

 

 

 

 

 

FORM ADV-E PAGE 2 

information is to make the examination certificates filed by an accountant pursuant to Rule 206(4)-2(a)(4)(i) under the Adviser Act (after that accountant 

has verified by actual examination the securities and funds of clients in the custody of an investment adviser) more accessible for inspection by the 

Commission staff and the public and will facilitate verification of compliance with examination requirements. See 17 CFR §275.206(4)-2(a)(4)(i). The 

Commission will maintain files of the information on Form ADV-E and will make the information publicly available. Any member of the public may 

direct to the Commission any comments concerning the accuracy of the burden estimate on page one of Form ADV-E, and any suggestions for reducing 

this burden. This collection of information has been reviewed by the Office of Management and Budget in accordance with the clearance requirements 

of 44 U.S.C. §3507. The applicable Private Act system of records is SEC-2, and the routine uses of the records are set forth at 40 FR 39255 (Aug. 27, 

1975) and 41 FR 5318 (Feb. 5, 1976).