REGULATIONS
Vol. 34 Iss. 5 - October 30, 2017

TITLE 21. SECURITIES AND RETAIL FRANCHISING
STATE CORPORATION COMMISSION
Chapter 20
Forms

NOTICE: The following forms used in administering the regulation were filed by the agency. The forms are not being published; however, online users of this issue of the Virginia Register of Regulations may click on the name of a form with a hyperlink to access it. The forms are also available from the agency contact or may be viewed at the Office of the Registrar of Regulations, 900 East Main Street, 11th Floor, Richmond, Virginia 23219.

Titles of Regulations: 21VAC5-10. General Administration - Securities Act.

21VAC5-20. Broker-Dealers, Broker-Dealer Agents and Agents of the Issuer.

21VAC5-30. Securities Registration.

21VAC5-40. Exempt Securities and Transactions.

21VAC5-45. Federal Covered Securities.

21VAC5-80. Investment Advisors.

Agency Contact: Jude C. Richnafsky, Senior Examiner, Division of Securities and Retail Franchising, State Corporation Commission, Tyler Building, 9th Floor, P.O. Box 1197, Richmond, VA 23218, telephone (804) 371-9415, or email jude.richnafsky@scc.virginia.gov.

FORMS (21VAC5-10)

Broker-Dealer and Agent Forms

Form BD - Uniform Application for Broker-Dealer Registration (rev. 1/08).

Form S.A.11 - Broker-Dealer's Surety Bond (rev. 7/99).

Form S.A.2 - Application for Renewal of a Broker-Dealer's Registration (rev. 7/99).

Form S.D.4 - Application for Renewal of Registration as an Agent of an Issuer (1997).

Form S.D.4.A - Non-NASD Broker-Dealer or Issuer Agents to be Renewed Exhibit (1974).

Form S.D.4.B - Non-NASD Broker-Dealer or Issuer Agents to be Canceled with no disciplinary history (1974).

Form S.D.4.C - Non-NASD Broker-Dealer or Issuer Agents to be Canceled with disciplinary history (1974).

Form BDW - Uniform Notice of Termination or Withdrawal of Registration as a Broker-Dealer (rev. 4/07).

Rev. Form U4 - Uniform Application for Securities Industry Registration or Transfer (rev. 5/09).

Rev. Form U5 - Uniform Termination Notice for Securities Industry Registration (rev. 5/09).

Form BD, Uniform Application for Broker-Dealer Registration (rev. 1/2008)

Form BDW, Uniform Notice of Termination or Withdrawal of Registration as a Broker-Dealer (rev. 4/2007)

Form S.A. 2, Application for Renewal of a Broker-Dealer's Registration (rev. 10/2017)

Form S.A. 11, Broker-Dealer's Surety Bond (rev. 7/1999)

Form S.D.4, Application for Renewal of Registration as an Agent of an Issuer (2017)

Form S.D.4.A, Agents to be Renewed - Exhibit I (rev. 1974)

Form S.D.4.B, Agents to be Canceled (Records Clear) - Exhibit II (rev. 1974)

Form S.D.4.C, Agents to be Canceled (Without clear Records) - Exhibit III (rev. 1974)

Rev. Form U4, Uniform Application for Securities Industry Registration or Transfer (rev. 5/2009)

Rev. Form U5, Uniform Termination Notice for Securities Industry Registration (rev. 5/2009)

Investment Advisor and Investment Advisor Representative Forms

Form ADV, Uniform Application for Registration of Investment Advisors (rev. 10/12).

Part IA.

Part IB.

Part 2.

Form ADV-W - Notice of Withdrawal from Registration as an Investment Advisor (rev. 11/10).

Surety Bond Form (rev. 7/99).

Rev. Form U - Uniform U4 - Uniform Application for Securities Industry Registration or Transfer (rev. 5/09).

Rev. Form U - Uniform U5 - Uniform Termination Notice for Securities Industry Registration (rev. 5/09).

Form S.A.3 - Affidavit for Waiver of Examination (rev. 7/99).

Form S.A.15 - Investment Advisor Representative Multiple Employment Agreement (eff. 7/07).

Form S.A.16 - Agent Multiple Employment Agreement (eff. 7/07).

Form ADV, Uniform Application for Registration of Investment Registration and Report by Exempt Reporting Advisers

Part IA, SEC 1707 (7/2017)

Part IB, paper version (rev. 10/2012)

Part 2, Uniform Requirements for the Investment Adviser Brochure and Brochure Supplements (undated)

Form ADV-W - Notice of Withdrawal from Registration as an Investment Advisor (rev. 11/2010)

Form S.A. 3, Affidavit for Waiver of Examination (undated, filed 10/2017)

Form S.A. 10, Investment Advisor's Surety Bond Form (rev. 10/2017)

Form S.A. 15, Investment Advisor Representative Multiple Employment Agreement (eff. 7/2007)

Form S.A. 16, Agent Multiple Employment Agreement (eff. 7/2007)

Rev. Form U4, Uniform Application for Securities Industry Registration or Transfer (rev. 5/2009)

Rev. Form U5, Uniform Termination Notice for Securities Industry Registration (rev. 5/2009)

Securities Registration and Notice Filing Forms

Form U-1 - Uniform Application to Register Securities (7/81).

Form U-2 - Uniform Consent to Service of Process (7/81).

Form U-2-a - Uniform Form of Corporate Resolution (rev. 7/99).

Form S.A.4 - Registration by Notification - Original Issue (rev. 11/96).

Form S.A.5 - Registration by Notification - Non-Issuer Distribution (rev. 11/96).

Form S.A.6 - Registration by Notification - Pursuant to 21VAC5-30-50 Non-Issuer Distribution "Secondary Trading" (1989).

Form S.A.8 - Registration by Qualification (7/91).

Form S.A.12 - Escrow Agreement (1971).

Form S.A.13 - Impounding Agreement (rev. 7/99).

Form VA - Parts 1 and 2 - Notice of Limited Offering of Securities (rev. 11/96).

Form NF - Uniform Investment Company Notice Filing (4/97).

Form U-1, Uniform Application to Register Securities (undated, filed 10/2017)

Form U-2, Uniform Consent to Service of Process (rev. 6/2016)

Form U-2A, Uniform Form of Corporate Resolution (rev. 6/2016)

Form S.A. 4, Registration by Notification - Original Issue (rev. 11/1996)

Form S.A. 5, Registration by Notification - Non-Issuer Distribution (rev. 11/1996)

Form S.A. 6, Registration by Notification - Non-Issuer Distribution "Secondary Trading" (1989)

Form S.A. 8, Registration by Qualification (rev. 7/1991)

Form S.A. 12, Escrow Agreement (1971)

Form S.A. 13, Impounding Agreement (rev. 7/1999)

Form VA-1, Parts 1 and 2, Notice of Limited Offering of Securities (rev. 11/1996)

Form NF, Uniform Investment Company Notice Filing (4/1997)

FORMS (21VAC5-20)

Form BD, Uniform Application for Broker-Dealer Registration, SEC 1490 (rev. 1/2008)

Form BDW, Uniform Request for Broker-Dealer Withdrawal, SEC 122 (rev. 4/2007)

Form S.A. 2, Application for Renewal of a Broker-Dealer's Registration (rev. 10/2017)

Form S.A. 11, Broker-Dealer's Surety Bond (rev. 7/1999)

Form S.D.4, Application for Renewal of Registration as an Agent of an Issuer (2017)

Form S.D.4.A., Agents to be Renewed - Exhibit I (rev. 1974)

Form S.D.4.B., Agents to be Canceled (Records Clear) - Exhibit II (rev. 1974)

Form S.D.4.C., Agents to be Canceled (Without Clear Records) - Exhibit III (rev. 1974)

Rev. Form U4, Uniform Application for Securities Industry Registration or Transfer (rev. 5/2009)

Rev. Form U5, Uniform Termination Notice for Securities Industry Registration (rev. 5/2009)

FORMS (21VAC5-30)

Form U–1, Uniform Application to Register Securities (undated, filed 10/2017)

Form U–2, Uniform Consent to Service of Process (rev. 6/2016)

Form U–2A, Uniform Form of Corporate Resolution (rev. 6/2016)

Form S.A. 4, Registration by Notification - Original Issue (rev. 11/1996)

Form S.A. 5, Registration by Notification - Non-Issuer Distribution (rev. 11/1996)

Form S.A. 6, Registration by Notification - Non-Issuer Distribution "Secondary Trading" (1989)

Form S.A. 8, Registration by Qualification (rev. 7/1991)

Form S.A. 12, Escrow Agreement (1971)

Form S.A. 13, Impounding Agreement (rev. 7/1999)

FORMS (21VAC5-40)

Form D, Notice of Exempt Offering of Securities, U.S. Securities and Exchange Commission, SEC1972 (rev. 2/2012)

Intrastate Crowdfunding Exemption, Form ICE (eff. 7/2015)

Notice of Limited Offering of Securities, Form VA-1, Parts 1 and 2 (rev. 11/1996)

Model Accredited Investor Exemption Uniform Notice of Transaction Form (undated, filed 10/2017)

FORMS (21VAC5-45)

Form D, Notice of Exempt Offering of Securities, U.S. Securities and Exchange Commission, SEC1972 (rev. 2/2012)

Uniform Consent to Service of Process, Form U-2 (7/1981)

Uniform Consent to Service of Process, Form U-2 (rev. 7/2017)

Uniform Notice of Regulation A - Tier 2 Offering (undated, filed 10/2016)

Form NF - Uniform Investment Company Notice Filing (4/1997)

FORMS (21VAC5-80)

Form ADV, Uniform Application for Investment Adviser Registration and Report by Exempt Reporting Advisers

Part IA, SEC 1707 (7/2017)

Part IB, paper version (rev. 10/2012)

Part 2, Uniform Requirements for the Investment Adviser Brochure and Brochure Supplements (undated)

Form ADV-W, Notice of Withdrawal from Registration as an Investment Advisor, SEC 777 (rev. 11/2010)

Form S.A. 3, Affidavit for Waiver of Examination (undated, filed 10/2017)

Form S.A. 10, Investment Advisor's Surety Bond Form (rev. 10/2017)

Form S.A. 15, Investment Advisor Representative Multiple Employment Agreement (eff. 7/2007)

Form S.A. 16, Agent Multiple Employment Agreement (eff. 7/2007)

Rev. Form U4, Uniform Application for Securities Industry Registration or Transfer, (rev. 5/2009)

Rev. Form U5, Uniform Termination Notice for Securities Industry Registration (rev. 5/2009)

VA.R. Doc. No. R18-5274; Filed October 3, 2017, 7:10 p.m.