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

Schedule Disposition versions

2012-09-01

Schedule 4

(s. 4)

DECLARATION PERTAINING TO THE ABSENCE 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 independent representative, having my principal establishment at _____________________________

declare the following:

— I do not intend to receive or collect any amounts on behalf of others in the pursuit of my activities governed by the Act and the regulations enacted thereunder;

— if, following this declaration, I receive or collect amounts on behalf of others in the pursuit of my activities, I undertake to comply with the provision of the Act and the regulations enacted thereunder respecting the establishment and maintenance of a separate account.

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

______________________________________________

(Signature of independent representative)

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. 4.