MSD-5 Uniform Termination Notice for Muncipal Securities Princ

Board of Governors of the Federal Reserve System
OMB No. 7100-0101 Expires April 30, 2010
Federal Deposit Insurance Corporation
OMB No. 3064-0022 Expires December 31, 2011
Office of the Comptroller of the Currency
OMB No. 1557-0184 Expires April 30, 2007

Form MSD-5
Uniform Termination Notice for
Municipal Securities Principal or
Municipal Securities Representative
Associated with a Bank Municipal Securities Dealer
The Board of Governors of the Federal Reserve System, the Federal
Deposit Insurance Corporation, and the Office of the Comptroller of the
Currency are authorized to collect this information pursuant to the
authority contained in the following statutes: 15 U.S.C. sections 78o-4,
78q, and 78w.
An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid
OMB control number. The information provided by each respondent is
considered to be confidential.

REPORTING BURDEN: Public reporting burden for this collection of
information is estimated to average 15 minutes per response, including
the time to gather and maintain data in the required form and to review
instructions and to complete the information collection. Send comments
regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to Office of
Management and Budget, Washington, DC 20503, and, depending on
your primary federal regulator, to Secretary, Board of Governors of the
Federal Reserve System, 20th and C Streets, N.W. Washington, DC
20551; or to Assistant Executive Secretary, Federal Deposit Insurance
Corporation, Washington, DC 20429; or to Legislative and Regulatory
Analysis Division, Office of the Comptroller of the Currency, Washington,
DC 20219.

PRIVACY ACT STATEMENT
The FDIC is authorized to request this information from you by Sections 15B(c), 15C, 17 and 23 of the Securities Exchange Act of 1934 (15 U.S.C. 78o-4, 78o-5, and 78q
and 78w); and Section 9 of the Federal Deposit Insurance Act (12 U.S.C. 1819). The purpose for collecting the information is to comply with the registration requirements of
municipal securities dealers, municipal securities representatives, and U.S. Government securities brokers or dealers and associated persons contained in the Securities
Exchange Act of 1934, and to support the FDIC's regulatory and supervisory functions. Furnishing the requested information is mandatory. Failure to provide the requested
information in whole or in part may delay or prohibit the determination of your compliance with applicable registration and professional qualifications requirements. The
information you provide is protected by the Privacy Act, 5 USC 552(a). The information may be furnished to third parties as authorized by law and used according to any of
the routine uses described in the Professional Qualification Records for Municipal Securities Dealers, Municipal Securities Representatives, and U.S. Government Securities
Brokers/Dealers System of Records (30-64-0016) available at http://www.fdic.gov/regulations/laws/rules/2000-4050.html#200030--64--0016. If you have questions or
concerns about the collection or use of the information, you may contact the FDIC’s Chief Privacy Officer at [email protected].”

FORM MSD-5
Uniform Termination Notice for
Municipal Securities Principal or Municipal Securities Representative
Associated with a Bank Municipal Securities Dealer
1.

INDIVIDUAL’S NAME
Last

2.

First

CAPACITY (check all that apply):
Municipal Securities ............................................................................... G

3.

SOCIAL SECURITY NUMBER (optional)

4.

BANK MUNICIPAL SECURITIES DEALER:
A. NAME
B.

REGISTRATION NUMBER

C.

MAIN ADDRESS

5.

OFFICE OF EMPLOYMENT ADDRESS

6.

DATE TERMINATED

Middle (if none, write “n/a”)
Government Securities................................................................G

Month
7.

Day

Year

REASON FOR TERMINATION (check one):
*RESIGNED .................................................................... G

DECEASED.........................................................................G

*DISCHARGED............................................................... G

*OTHER . ............................................................................G

*FURNISH FULL DETAILS ON ATTACHED SHEET IF RELATED TO A VIOLATION OR PROBABLE VIOLATION OF BANKING OR SECURITIES LAW.
8.

While associated with the dealer named in item 4, was the individual named in item 1 the subject of any investigation, proceeding, disqualification,
or disciplinary action by any government agency or self-regulatory organization (as defined in section 3(a)(26) of the Securities Exchange Act of
1934) described in Rules G-4 and G-5 of the Municipal Securities Rulemaking Board?

**YES

G

NO

G

** FURNISH FULL DETAILS ON ATTACHED SHEET.

9.

TO BE FILED WITH THE FOLLOWING (check one):
Comptroller of the Currency

Date

G

Board of Governors of the Federal Reserve System

Print Name of Municipal
Securities Principal

G

Federal Deposit Insurance Corporation

G

Signature of Municipal
Securities Principal

PERSON TO CONTACT FOR FURTHER INFORMATION

ACCEPTANCE OF THIS FORM FOR FILING SHALL NOT CONSTITUTE ANY FINDING THAT THE INFORMATION SUBMITTED HEREIN IS TRUE,
CURRENT, COMPLETE, OR NOT MISLEADING. INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT MAY CONSTITUTE FEDERAL
CRIMINAL VIOLATIONS. (See 18 U.S.C. sections 1001 and 1005, and 15 U.S.C. 78ff.)

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Acknowledgement for
FORM MSD-5 G
FORM G-FIN-5 G

10. NAME OF PERSON TERMINATED
Last

First

Middle (if none, write “n/a”)
Return Receipt

11. Bank Municipal Securities Dealer Name

12. Bank Municipal Securities Dealer Address

13. Attention:

WHEN THE FORM MSD-5 IS RECEIVED BY THE APPROPRIATE REGULATORY AGENCY, THIS ACKNOWLEDGEMENT WILL BE STAMPED TO
SHOW RECEIPT AND RETURNED TO THE PERSON NAMED IN ITEM 13. THE STAMPED ACKNOWLEDGEMENT SHOULD BE RETAINED TO
SUBSTANTIATE FILING.

Mail the form to the Regulator indicated in item 9
The Office of the Comptroller of the Currency
Treasury and Market Risk (MS 7-1)
250 E. Street, S.W.
Washington, DC 20219
Board of Governors of the Federal Reserve System
Market and Liquidity Risk Section
Mail Stop 185
20th and C Streets, N.W.
Washington, DC 20551
Federal Deposit Insurance Corporation
Division of Supervision and Consumer Protection
Policy and Program Development Section
Room F-6044
550 17th Street, N.W.
Washington, DC 20429

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