Name:

Report Charged with Late Filing Fee: Statement of Registration January/February Bimonthly Report March/April Bimonthly Report May/June Bimonthly Report July/August Bimonthly Report September/October Bimonthly Report November/December Bimonthly Report Client Semi-Annual Report

year: 2004 2005 2006 2007 2008

Check Here if Report Charged with Late Filing Fee is an Amendment:

For name (client or public corporation):

Amount of Late Filing Fee:

Justification for Waiver:

I declare under penalty of perjury that the information contained in this Application is true, correct, and complete to the best of my knowledge and belief.

Signature:

__________________________________________

Date:

Print/Type Name: