Licensee Reporting Form - California Board of Accountancy

LICENSEE REPORTING

FORM

CALIFORNIA BOARD OF ACCOUNTANCY REPORTABLE EVENTS

Pursuant to California Business and Professions Code, Division 3, Chapter 1, section 5063

and

California Code of Regulations, Title 16, sections 59, 60, and

(Please read the attached information before completing and submitting this

form.)

LICENSED ACCOUNTANT AND/OR LICENSED ACCOUNTING FIRM

Licensee Name License Number

Company Name License Number

Address

Telephone ( )

TYPE OF REPORTABLE EVENT

Please check the appropriate box.

Felony Conviction [as defined in section 5063(a)(1)(A)]

Criminal Conviction [as defined in section 5063(a)(1)(B)]

Criminal Conviction [as defined in section 5063(a)(1)(C)]

Cancellation, revocation, or suspension of a certificate, other authority to practice as

a certified public accountant or a public accountant, by any other state or foreign

country [as defined in section 5063(a)(2)]

Cancellation, revocation, or suspension of the right to practice as a certified public

accountant or a public accountant before any governmental body or agency [as

defined in section 5063(a)(3)]

Restatement of a financial statement [as defined in sections 5063(b)(1), 5063.10 and CCR section 59]

Civil action settlement [as defined in section 5063(b)(2) and CCR section 61]

Civil action arbitration award [as defined in section 5063(b)(2) and CCR section 61] Any

notice of the opening or initiation of an investigation of the licensee by the Securities

and Exchange Commission [as defined in section 5063(b)(3) and CCR section 60] Any notice

from the Securities and Exchange Commission requesting a Wells Submission [as

defined in section 5063(b)(4) and CCR section 60]

Any notice of the opening or initiation of an investigation by the Public Company

Accounting Oversight Board [as defined in section 5063(b)(5) and CCR section 60]

Civil action judgment [as defined in section 5063(c)(1), (2), (3),( 4) and (5)and CCR section 61]

11l-55(4/17w)

EXPLANATION FOR REPORTABLE EVENT

1. Summary (Attach additional sheets if necessary):

2. If the reportable event involves a Restatement, please submit copy of the original and

restated financial statement or the portions of the original and amended Form 990 or 990PF

related to the reissued financial statement.

3. If the reportable event involves a civil action settlement or arbitration award that is $30,000

or greater, please provide:

Total Amount Paid by Insurer Date Paid

Total Amount Paid by Licensee Date Paid

4. If the reportable event involves an administrative agency action or court action, please

provide:

Title of

Matter

Docket

Number

Dates of Occurrence

Court, Arbitrator, or Agency Name and Address

I certify under penalty of perjury under the laws of the state of California that to the best

of my knowledge the information provided within this report and any attachments is true

and correct.

Signature: Date:

The following are excerpts from the California Business and Professions Code.

Section 5063(a). A licensee shall report to the board in writing of the occurrence of any of the following

events occurring on or after January 1, 1997, within 30 days of the date the licensee has knowledge of

these events:

(1) The conviction of the licensee of any of the following:

(A) A felony.

(B) Any crime related to the qualifications, functions, or duties of a public accountant or certified public

accountant, or to acts or activities in the course and scope of the practice of public accountancy.

responsibility, or the preparation, publication, or dissemination of false, fraudulent, or materially

misleading financial statements, reports, or information.

As used in this section, a conviction includes the initial plea, verdict, or finding of guilt, pleas of no

contest, or pronouncement of sentence by a trial court even though that conviction may not be final or

sentence actually imposed until appeals are exhausted.

(2) The cancellation, revocation, or suspension of a certificate, other authority to practice or refusal to

renew a certificate or other authority to practice as a certified public accountant or a public

accountant, by any other state or foreign country.

(3) The cancellation, revocation, or suspension of the right to practice as a certified public accountant or

a public accountant before any governmental body or agency.

Section 5063(b). A licensee shall report to the board in writing the occurrence of any of the following

events occurring on or after January 1, 2003, within 30 days of the date the licensee has knowledge of

the events:

(1) Any restatement of a financial statement and related disclosures by a client audited by the

licensee.

(2) Any civil action settlement or arbitration award against the licensee relating to the practice of

public

accountancy where the amount or value of the settlement or arbitration award is thirty

thousand

dollars ($30,000) or greater and where the licensee is not insured for the full amount of the award.

(3) Any notice of the opening or initiation of a formal investigation of the licensee by the Securities and

Exchange Commission or its designee.

(4) Any notice from the Securities and Exchange Commission to a licensee requesting a Wells

Submission.

(5) Any notice of the opening or initiation of an investigation by the Public Company Accounting

Oversight Board or its designee, as defined pursuant to subdivision (g).

Section 5063(c). A licensee shall report to the board in writing, within 30 days of the entry of the

judgment, any judgment entered on or after January 1, 2003, against the licensee in any civil action

alleging any of the following:

(1) Dishonesty, fraud, gross negligence, or negligence.

(2) Breach of fiduciary responsibility.

(3) Preparation, publication, or dissemination of false, fraudulent, or materially misleading financial

statements, reports, or information.

(4) Embezzlement, theft, misappropriation of funds or property, or obtaining money, property, or other

valuable consideration by fraudulent means or false pretenses, or other errors or omissions.

(5) Any actionable conduct by the licensee in the practice of public accountancy, the performance of

bookkeeping operations, or other professional practice.

Section 5063(d). The report required by subdivisions (a), (b), and (c) shall be signed by the licensee and

set forth the facts which constitute the reportable event. If the reportable event involves the action of an

administrative agency or court, then the report shall set forth the title of the matter, court or agency name,

docket number, and dates of occurrence of the reportable event.

Section 5063(e). A licensee shall promptly respond to oral or written inquiries from the board in

conjunction with license renewal.

Section 5063(f). Nothing in this section shall impose a duty upon any licensee to report to the board the

occurrence of any of the events set forth in subdivision (a), (b), or (c) either by or against any other

licensee.

Section 5063(g). The board may adopt regulations to further define the reporting requirements of this

section.

Section 5063.10(a). Any restatement of a financial statement that is included in any report filed with

the United States Securities and Exchange Commission shall be exempt from the requirement

described in paragraph (1) of subdivision (b) of section 5063.

(b) Nothing in this section shall be construed to require the reporting of any restatement of a financial

statement that is not required to be submitted to the board pursuant to the regulations adopted by the

board in effect on the date this section becomes operative.

The following are excerpts from the California Code of Regulations, Title 16.

Section 59. (a) To comply with the requirements of paragraph (1) of subdivision (b) of Business and

Professions Code section 5063, a licensee who issues a report on a client’s restated financial statement

shall report to the Board:

(1) Any restatement of a financial statement reporting the correction of any error in a previously issued

financial statement of a client that is:

(A) A publicly traded company that is required to file a tax return with the California Franchise Tax

Board; or

(B) A government agency located in California, when the financial restatement(s) exceeds the

planning materiality used by the licensee in conjunction with the current year audit. For purposes

of this paragraph, planning materiality means the planned level of misstatements, individually or in

aggregate, that would cause the financial statements to not be presented fairly, in all material

respects, in conformity with generally accepted account principles.

(2) Any restatement of a financial statement of a charitable organization registered by the Office of the

Attorney General’s Registry of Charitable Trusts which is issued for purposes of correcting any error

in a previously issued financial statement and which has resulted in the filing of an amended or

superseding Internal Revenue Service Form 990 or 990PF.

(b) The report required by subsection (a) shall be made by the licensee issuing the report on the

restatement even if the licensee did not perform the original audit. The report required by subsection (a)

shall be provided to the Board within 30 days of issuance of the restatement, shall be signed by the

licensee, and shall set forth the facts which constitute the reportable event including an explanation of the

reason for the restatement. The report made under paragraph (a)(1) of this section shall include copies of

the original and the restated financial statements. The report made under paragraph (a)(2) of this section

shall include only those portions of the original and the amended Forms 990 and 990PF related to the

reissued financial statement.

Section 60. (a) For purposes of reporting pursuant to section 5063(b)(5), notice of the opening or

initiation of an investigation by the Public Company Accounting Oversight Board shall include any notice

by the Public Company Accounting Oversight Board that it is initiating an investigation of the licensee.

(b) Reports received by the Board pursuant to the requirements of subsection (a) of this section or of

paragraphs (3), (4), or (5) of subdivision (b) of Business and Professions Code 5063 shall not be publicly

disclosed other than (1) in the course of any disciplinary proceeding by the Board after the filing of

formal

accusation; (2) in the course of any legal action to which the Board is a party; (3) in response to an

official inquiry from a state or federal agency; (4) in response to a subpoena or summons enforceable by

order of a court; or (5) when otherwise specifically required by law.

Section 61. (a) To meet the reporting requirements of paragraph (b)(2) of section 5063, licensees shall

report settlements and arbitration awards consistent with that provision that are the result of actions

brought by persons located, residing, or doing business in California.

(b) Reports of judgments in civil actions alleging negligent conduct (but not dishonesty, fraud, or gross

negligence) by a licensee pursuant to paragraph (c)(1) of section 5063 shall be limited to those

judgments in which a person located, residing in or doing business in California is a named party to the

action or where the alleged conduct relates to the practice of public accountancy in California. Nothing in

this subsection limits a licensee’s responsibility to report under any other paragraph of subdivision (c) of

section 5063.

be publicly disclosed other than (1) in the course of any disciplinary proceeding by the Board after the

filing of a formal accusation; (2) in the course of any legal action to which the Board is a party; (3) in

response to an official inquiry from a state or federal agency; (4) in response to a subpoena or summons

enforceable by order of a court; or (5) when otherwise specifically required by law.

PERSONAL INFORMATION COLLECTION AND ACCESS NOTICE: The California

Board of Accountancy (CBA) collects the information requested on this form as

authorized by Business and Professions Code sections 325, 326, and 5103. The

personal information collected is used principally to administer and to enforce licensing

standards set by law and regulation. The personal information provided may be

transferred to the Department of Justice, a District Attorney, a City Attorney, or to

another government agency as may be necessary to permit the CBA, or the transferee

agency, to perform its statutory or constitutional duties, or otherwise transferred or

disclosed as permitted by the Information Practices Act. Each individual has the right to

review his or her personal information in his or her file, except as otherwise permitted by

the Information Practices Act. Certain information provided may be disclosed to a

member of the public, upon request, under the California Public Records Act and

Information Practices Act.