D-9.2, r. 15 - Regulation respecting the registration of firms, representatives and independent partnerships

Schedule Disposition versions

2012-09-01

Schedule 1-A

(s. 2)

DECLARATION PERTAINING TO THE OPENING OF A SEPARATE ACCOUNT

To: Autorité des marchés financiers

Place de la Cité, tour Cominar, 2640, boulevard Laurier, bureau 400, Québec (Québec) G1V 5C1

for the application of the Act respecting the distribution of financial products and services (chapter D-9.2) and the regulations enacted thereunder.

I, the undersigned, ______________________________, as an officer of the firm __________(name of firm)__________, having its principal establishment at ______________________________

declare the following:

— the separate account bearing number ______________________________ is open at the following financial institution:______________________________;

— such account is composed of amounts which are received or collected by the firm on behalf of others in the pursuit of its activities governed by the Act and the regulations enacted thereunder;

— such account is governed by the Act and the regulations enacted thereunder;

— in accordance with our records, the persons whose names and signatures appear hereinafter are authorized to sign any document on behalf of the firm pertaining to the day-to-day operation of such account:

(Name)____________________________________(Signature) ____________________________________

(Name)____________________________________(Signature) ____________________________________

— the Autorité des marchés financiers is authorized to require and obtain at all times, from our institution, any information, explanation or copy of a document which is necessary or useful for purposes of verifications in respect of such account.

IN WITNESS WHEREOF, I have signed in ______________________________ on this __________ day of the month of ______________________________ of the year __________.

______________________________________________

(Signature of firm’s officer)

Declared under oath before me in ______________________________ on this __________ day of the month of ______________________________ of the year __________.

Commissioner for Oaths for the Judicial District of ______________________________

____________________________________________

(Signature of the commissioner)

Decision 99.07.09, Sch. 1-A.