Fillable Printable Form X-17A-5 Part Iii
Fillable Printable Form X-17A-5 Part Iii
Form X-17A-5 Part Iii
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ANNUAL AUDITED REPORT
FORM X-17A-5
PART III
OMB APPROVAL
OMB Number: 3235-0123
Expires:
August 31, 2020
Estimated average burden
hours per response.. . . . . 12.00
UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
SEC FILE NUMBER
8-
FACING PAGE
Information Required of Brokers and Dealers Pursuant to Section 17 of the
Securities Exchange Act of 1934 and Rule 17a-5 Thereunder
REPORT FOR THE PERIOD BEGINNING______________________________ AND ENDING______________________________
MM/DD/YY MM/DD/YY
A. REGISTRANT IDENTIFICATION
NAME OF BROKER-DEALER:
ADDRESS OF PRINCIPAL PLACE OF BUSINESS: (Do not use P.O. Box No.)
OFFICIAL USE ONLY
FIRM I.D. NO.
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(No. and Street)
(City) (State) (Zip Code)
NAME AND TELEPHONE NUMBER OF PERSON TO CONTACT IN REGARD TO THIS REPORT
(Area Code – Telephone Number)
B. ACCOUNTANT IDENTIFICATION
INDEPENDENT PUBLIC ACCOUNTANT whose opinion is contained in this Report*
(Name – if individual, state last, first, middle name)
(Address) (City) (State) (Zip Code)
CHECK ONE:
Certified Public Accountant
Public Accountant
Accountant not resident in United States or any of its possessions.
FOR OFFICIAL USE ONLY
*Claims for exemption from the requirement that the annual report be covered by the opinion of an independent public accountant
must be supported by a statement of facts and circumstances relied on as the basis for the exemption. See Section 240.17a-5(e)(2)
Potential persons who are to respond to the collection of
information contained in this form are not required to respond
SEC 1410 (06-02)
unless the form displays a currently valid OMB control number.
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OATH OR AFFIRMATION
I , ___________________________________________________________________________ , s w e a r ( o r a f f i r m ) t h a t , t o t he b e s t o f
my knowledge and belief the accompanying financial statement and supporting schedules pertaining to the firm of
_____________________________________________________________________________________________________________ , as
o f _________________________________________________, 2 0_ _______, are true and correct. I further swear (or affirm) that
neither the company nor any partner, proprietor, principal officer or director has any proprietary interest in any account
classified solely as that of a customer, except as follows:
Signature
Title
Notary Public
This report ** contains (check all applicable boxes):
(a) Facing Page.
(b) Statement of Financial Condition.
(c) Statement of Income (Loss).
(d) Statement of Changes in Financial Condition.
(e) Statement of Changes in Stockholders’ Equity or Partners’ or Sole Proprietors’ Capital.
(f) Statement of Changes in Liabilities Subordinated to Claims of Creditors.
(g) Computation of Net Capital.
(h) Computation for Determination of Reserve Requirements Pursuant to Rule 15c3-3.
(i) Information Relating to the Possession or Control Requirements Under Rule 15c3-3.
( j ) A Reconciliation, including appropriate explanation of the Computation of Net Capital Under Rule 15c3-1 and the
Computation for Determination of the Reserve Requirements Under Exhibit A of Rule 15c3-3.
(k) A Reconciliation between the audited and unaudited Statements of Financial Condition with respect to methods of
consolidation.
(l) An Oath or Affirmation.
(m) A copy of the SIPC Supplemental Report.
(n) A report describing any material inadequacies found to exist or found to have existed since the date of the previous audit.
**For conditions of confidential treatment of certain portions of this filing, see section 240.17a-5(e)(3).
