G-FIN Notice by Financial Institutions of Government Securitie

OMB# 1557-0184
EXPIRES 5/31/2013

Form G-FIN
Notice of Government Securities Broker or
Government Securities Dealer Activities

To Be Filed by a Financial Institution Under Section 15C(a)(1)(B)
Of the Securities Exchange Act of 1934
1.

Appropriate regulatory agency (check one):
A.
B.
C.
D.
E.

□
□
□
□
□

2.

Comptroller of the Currency

A.

Board of Governors of the Federal Reserve System

B.

Federal Deposit Insurance Corporation

C.

□
□
□

3.

Filing status of notice (check as applicable):

Securities and Exchange Commission

E.

Government Securities Dealer
Government Securities Broker & Dealer

□
□

Notice
Amendment

A.

Full name of the Financial Institution:

B.

Address of principal office of Financial Institution:

C.

Address of principal office where government securities broker or government securities dealer activities will be
conducted (if different than item (B)):

D.

Mailing address if different from (B) or (C):

E.

Name, title and telephone number of contact person with respect to this notice:

Name

5.

Government Securities Broker

Office of Thrift Supervision

D.

4.

Filing status of notice (check as applicable):

Title

Telephone

Does the Financial Institution conduct, or will it conduct, government securities broker or government securities dealer
activities at any location other than given in Question 4 above?
(If yes, provide addresses and describe activities.)

A.

□Yes

B.

□No

6.

Furnish the name and title of each person who is directly engaged in the management, direction or supervision of any
of the financial institution's government securities broker or government securities dealer activities:
Full Name
Last

First

Middle

Title

Last

First

Middle

Title

Last

First

Middle

Title

Last

First

Middle

Title

Last

First

Middle

Title

Note: Attach a separate Form G-Fin-4 (or, if previously filed, a copy of Form MSD-4 or Form U-4) for each person
named in response to Item 6.
7.

Has any "associated person" (see definition in paragraph A.7. of the Instructions) responded "yes" to any question in
Item 17 of Form G-Fin-4, or "yes" to one or more questions in Items 20 through 25 of Form MSD-4 or Item 22 on Form
U-4?

A.

□ Yes

B.

□

No

(If yes, attach a copy of Form G-FIN-4, Form MSD-4, or Form U-4 for all such persons with this Notice).
Note: The financial institution and the person executing this form are responsible for making an inquiry of all other
employers of any associated person during the immediately preceding three years for the purpose of verifying the
accuracy of the information furnished on Form G-FIN-4. (See 17 C.F.R. 400.4(c). Similar requirements are
applicable to Form MSD-4 and Form U-4.)
8.

The financial institution submitting this notice and the person executing it represent that all of the
information contained herein is true, current and complete.
Please print name and title of person executing this notice:

First

Manual Signature

Middle

Last

Title

Date