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

Schedule Disposition versions

2012-09-01

Schedule 3

(s. 4)

DECLARATION PERTAINING TO THE OPENING OF A SEPARATE ACCOUNT

To: __________(Name and address of the financial institution)__________ 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:

— the separate account bearing number ______________________________ is open at your institution in the name of ______________________________;

— such account is composed of amounts which are received or collected on behalf of others in the pursuit of my 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 your records, the persons whose names and signatures appear hereinafter are authorized to sign any document 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 your 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 independent representive)

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. 3.