The AICPA Stockbrokerage and Investment Banking Expert Panel together with SIFMA Financial Management Society has developed these illustrative exemption report examples for information purposes only. The exemption report required by SEC Rule 17a-5 is the responsibility of the SEC-registered broker-dealer. Broker-dealer firms should seek the advice of their own legal and/or other advisers with respect to their exemption reports.

Example 1 – Exemption Report when claiming a single exemption under the provisions of 17 C.F.R. § 240.15c3-3(k)

[Company]’s Exemption Report

[Name of Company] (the “Company”) is a registered broker-dealer subject to Rule 17a-5 promulgated by the Securities and Exchange Commission (17 C.F.R. §240.17a-5, “Reports to be made by certain brokers and dealers”). This Exemption Report was prepared as required by 17 C.F.R. § 240.17a-5(d)(1) and (4). To the best of its knowledge and belief, the Company states the following:

(1) The Company claimed an exemption from 17 C.F.R. § 240.15c3-3 under the following provisions of 17 C.F.R. § 240.15c3-3 (k): [ ]1

(2) The Company met the identified exemption provisions in 17 C.F.R. § 240.15c3-3(k) throughout the most recent fiscal year without exception.

or

(2) The Company met the identified exemption provisions in 17 C.F.R. § 240.15c3-3(k) throughout the most recent fiscal year except as described below.

[If applicable, identify each exception during the most recent fiscal year and briefly describe the nature of each exception and the approximate date(s) on which the exception existed.]

_______________________
[Name of Company]
I, _______________, swear (or affirm) that, to my best knowledge and belief, this Exemption
Report is true and correct.
By: [Signature line]
Title:
[Date of report]

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