I have read and fully understand Public Act 20 of 1943, as amended, and the Investment Policy of ________________________.

Any investment advice or recommendation given by __________________, representing ________________________, to the _______________ shall comply with the requirements of Public Act 20 of 1943, as amended, and the Investment Policy of ________________________. Any existing investment not conforming with the statute or the policy will be disclosed promptly.
 

By: _____________________