Child Support Certification Form And Tax Declaration For Broker-Dealer Agents And Investment Adviser Representatives - Vermont Department Of Banking
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1VERMONT DEPARTMENT OF BANKING, INSURANCE, SECURITIES
AND HEALTH CARE ADMINISTRATION
SECURITIES DIVISION
CHILD SUPPORT CERTIFICATION AND TAX DECLARATION
FOR BROKER-DEALER AGENTS AND INVESTMENT ADVISER REPRESENTATIVES
Child Support Obligations. Vermont Law requires that a professional license, which includes registration
as a BROKER-DEALER AGENT and registration as an INVESTMENT ADVISER REPRESENTATIVE,
shall not be issued or renewed unless the licensed individual certifies that he or she is in good standing with
respect to or in full compliance with a plan to pay any and all child support payable under a support order as
of the date the application for licensure (original or renewal application) is filed. “Good standing” means
that: (i) less than one-twelfth of the annual support obligation is overdue; (ii) liability for any support
payable is being contested in a judicial or quasi-judicial proceeding; (iii) the person is in compliance with a
repayment plan approved by the Office of Child Support or agreed to by the parties; or (iv) the licensing
authority determines that immediate payment of support due and payable would impose an unreasonable
hardship. (See 15 V.S.A. § 795)
Vermont Tax Obligations. Vermont Law also requires that a professional license, which includes
registration as a BROKER-DEALER AGENT and registration as an INVESTMENT ADVISER
REPRESENTATIVE, shall not be issued or renewed unless the licensed individual declares, under pains
and penalties of perjury, that he or she is in good standing with respect to any and all taxes payable under
Vermont law. “Good standing” means that: (i) no Vermont state taxes are due and payable and all returns
have been filed; (ii) the tax liability is on appeal; (iii) the taxpayer is in compliance with a payment plan
approved by the Commissioner of Taxes; or (iv) the licensing authority determines that immediate payment
of taxes would impose an unreasonable hardship. If the agency finds unreasonable hardship, it may
condition renewal of registration on terms which will place the person in good standing as soon as
reasonably possible. The maximum penalty for perjury is up to fifteen years in prison, a $10,000 fine, or
both. (See 32 V.S.A. § 3113)
I hereby certify that as of the date of this certification I am not subject to any child support order, or, if I am
subject to a child support order, I am in good standing (as defined above) with respect thereto or in full
compliance with a plan to pay any and all child support payable under each such support order. I hereby
declare, under the pains and penalties of perjury, that I am in good standing (as defined above) with respect
to or in full compliance with a plan to pay, any and all taxes due under Vermont law as of the date of this
declaration.
Date_______________
Name_________________________________________________
Social Security # _____________
Signature______________________________________________
Home Address_________________________________________________________________________
Name of Affiliated Investment Adviser or Broker-Dealer, as applicable: __________________________
_____________________________________________________________________________________
VT Office Address__________________________________________________ VT Phone__________
PLEASE NOTE: If you are not presently in good standing with the Vermont Department of Taxes you
may contact them at 802-828-2518. If you are not presently in full compliance with a child support order or
plan to pay child support, you may contact the Office of Child Support Services at 800-786-3214. This
form may be duplicated as needed.
Vermont Department of Banking, Insurance Securities and Health Care Administration, Securities Division
89 Main St., Montpelier, Vermont 05620-3101
Revised September 2007
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