Sample OBA form

Disclosures

This sample Outside Business Activity Reporting Form has not been customized to your investment adviser's business model, the specific investment advisory rules of your investment adviser's securities regulator or your investment adviser's written supervisory procedures and code of ethics. This sample Outside Business Activity Reporting Form may not be applicable or appropriate for your investment adviser. Due to changes of investment adviser laws and rules, this sample Outside Business Activity Reporting Form may become outdated and need to be updated or discontinued. This sample Outside Business Activity Reporting Form is not a substitute for retaining a compliance professional to advise and assist you regarding your investment adviser's compliance program. Unless otherwise agreed to in writing, you understand that RIA Compliance Consultants, Inc. is not responsible for: customizing this sample Outside Business Activity Reporting Form; implementing the use of this sample Outside Business Activity Reporting Form, updating this Outside Business Activity Reporting Form, preparing your investment adviser's written supervisory procedures or code of ethics, or notifying you of changes to the investment advisor laws and rules.

?2012 RIA Compliance Consultants, Inc.

Outside Business Activity Reporting Form (Firm Name)

Employee Name:

As an Investment Adviser, (Firm Name) has a fiduciary duty to provide full and fair disclosure to our clients. This disclosure includes any situations that may present a conflict of interest. In order to make sure that we provide proper disclosure to our clients, (Firm Name) must retain a current record of all outside business activities conducted by supervised persons. It is important that you notify us promptly if you are, or plan to be, involved in any outside business activity or employment. Non-investment related activities that are exclusively charitable, civic, religious or fraternal and recognized as tax-exempt may be excluded unless you serve on the board of directors or have some other control capacity within the organization and the organization is a current or potential client. Notification must be made prior to engaging in any outside activities or employment.

The following information must be completed fully and accurately. Completion and submission of this Form will be considered your notification to (Firm Name) of any outside business activities or employment that you will engage in. A copy of this Form should be retained for your records and changes should be reported promptly. A separate form should be completed for each activity.

1. Are you currently or do you plan to be involved in any business other than (Firm Name)?

Yes

No

If yes, please answer the following questions:

2. Full legal name of other business:

3. Are you using a Doing Business As Name (dba) with this outside activity:

Yes

No

If yes, dba name:

4. Organizational status of this business: (i.e.,corp,ptnrshp, sole prop, LLC)

5. Address of other business:

Street

City

State

Zip

6. Phone Number:

7. Is this business investment-related?

Yes

No

?2012 RIA Compliance Consultants, Inc.

8. Nature of other business: (i.e., insurance agency, registered representative, real estate)

9. Are you:

W-2 employee

1099 employee

Director

Manager

Other

10. Your position, title or relationship with company:

Officer Explain:

11. Date of employment:

12. Are you: Full-time:

Part-time:

13. Your obligation to other business:

Approximate number of hours per month:

How many hours during securities trading hours:

14. Briefly describe your primary duties relating to Other Business:

15. What products or services are offered through this business?

16. How are you compensated by this business?

17. What is your estimated gross annual compensation from this activity/job?

18. What percentage of your gross annual income does this represent?

19. Your ownership interests: (Check all that apply)

None 100% Owner Partner (Partnership)

Ownership: General Partner

?2012 RIA Compliance Consultants, Inc.

% %]

Limited Partner

Shareholder (Corporation) Ownership:

%]

Majority

Minority

Member (LLC) Ownership:

%

Managing Member

Non-managing Member

20. If you indicated an ownership interest in this business, what is the total dollar amount of such interest?

$

21. Are any of your advisory clients also clients of this business?

Yes

No

22. Do you maintain a separate filing system for your advisory clients?

Yes

No

23. Do you maintain a separate bank account for this business? Yes

No

24. Are funds received for advisory services performed deposited in that bank

account?

Yes

No

25. If you do not own 100% of this business, please complete the following:

Name(s) of other owners, their ownership percentage, and whether the individual or entity is now, or has ever been registered or licensed as an Investment Adviser (IA), Investment Adviser Representative (IAR), BrokerDealer (BD), or Registered Representative (RR):

Name

Percentage

Registered

% Yes

No

% Yes

No

% Yes

No

% Yes

No

If any of the above listed owners is a business entity, do you have any ownership interest in

that entity? Yes

No

If yes, what percentage?

%

Which entity:

If any of the above individuals or entities are now or previously were registered with any of the following regulators: SEC, NASD, or state, as a RIA, IAR, BD, or RR (status), please complete the following:

?2012 RIA Compliance Consultants, Inc.

Name

Status

Jurisdiction

26. Is this activity currently disclosed on your Form U4?

Yes

No

I hereby certify that the information provided in this document is complete and accurate to the best of my knowledge. I authorize (Firm Name) to investigate my outside business activities and contact any entities or individuals affiliated with such outside business activities. In addition, I authorize these entities or individuals to release to (Firm Name) any information that it requests about my employment, affiliation and/or activities with this organization. I understand that I am responsible for providing current and accurate information to (Firm Name). If any of the above information changes or becomes inaccurate, I will promptly notify (Firm Name).

Signature:

Supervised Person Signature

Supervised Person Name (print)

Date

Received and Reviewed: Verifications/Notes/Comments:

Supervisor Signature

Printed Name & Title

Date

?2012 RIA Compliance Consultants, Inc.

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