USA Patriot Act of 2001 - Anti Money Laundering by uwn15494


									              ASSURITY ADVISORS™, INC.                                     P.O. Box 84310 • Lincoln, NE 68501-4310
              A Registered Investment Advisory Firm                         Phone: (800) 284-8576 • Fax (402) 458-2188

                        USA Patriot Act of 2001 - Anti Money Laundering

Under the USA Patriot Act of 2001, each financial institution is required to actively take steps to identify and prevent any
activity that facilitates money laundering and/or the funding of terrorist activities.
As custodian, ASSURITY ADVISORS, INC. is required to conduct inquiry to the identity of each client and account that
is opened and required to maintain surveillance of accounts for activities of a suspicious nature.
As custodian, ASSURITY ADVISORS, INC. is requesting the following information, as required by the USA Patriot Act.

Client Name                                                                   State of Residency

Driver’s License Number & State*

*If a driver’s license number cannot be provided, a form of picture ID needs to be presented and noted below.

The following documents(s) of identity were provided:

Complete the Information Below and Fax or Mail to: Assurity Advisors, Inc.

Client Signature                                                                             Date

Assurity Advisors Investment Advisor Signature                                               Date
Fax: (402) 458-2188         Phone: (800) 284-8576                                     P.O. Box 84310, Lincoln, NE 68501

02-736-04617                                                                                                     12.12.05

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