Form MSD-5 Form MSD-5 Uniform Termination Notice for Municipal Securities Prin

Board of Governors of the Federal Reserve System OMB Number 7100-0101 Approval expires April 30, 2016
Federal Deposit Insurance Corporation
OMB Number 3064-0022 Approval expires March 31, 2018
Office of the Comptroller of the Currency
OMB Number 1557-0184 Approval expires May 31, 2016
Page 1 of 3

Board of Governors of the Federal Reserve System

Uniform Termination Notice for Municipal Securities Principal or
Municipal Securities Representative Associated with a
Bank Municipal Securities Dealer—Form MSD-5
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. §§ 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.

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, NW, Washington, DC 20551; or to Assistant Executive Secretary, Federal Deposit Insurance Corporation, Washington, DC 20429; or to Legislative
and Regulatory Activities Division, Office of the Comptroller of the Currency, Washington, DC 20219.
06/2015

Form MSD-5
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Uniform Termination Notice for Municipal Securities Principal or
Municipal Securities Representative Associated with a
Bank Municipal Securities Dealer
1. Individual's Name:
Last

First

Middle (if none, write "n/a")

2. Capacity (check all that apply):
Municipal Securities

3. Social Security Number (optional):

Government Securities

4. Bank Municipal Securities Dealer:

5. Office of Employment Address:

A.
Name

Street Address

Registration Number

City

B.
C.

Zip Code

6. Date Terminated:

Main Street Address

City

State

State

Zip Code

Month/Day/Year

7. Reason for Termination (check one):
Resigned*

Discharged*

Other*

Deceased

*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**

No

**Furnish full details on attached sheet.
9. To be filed with the following (check one):
Board of Governors of the Federal Reserve System

Federal Deposit Insurance Corporation

Comptroller of the Currency

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. §§ 1001 and 1005,
and 15 U.S.C. 78ff.)

Print Name of Municipal Securities Principal

Signature of Municipal Securities Principal

Date

Person to Contact for Further Information:
Name
Street Address
City

State

Zip Code

Area Code / Phone Number

04/2013

Form MSD-5
Page 3 of 3

Acknowledgement for:

Form MSD-5

Form G-FIN-5

10.
Name of Person Terminated

11.
Bank Municipal Securities Dealer Name

12.

Receipt Stamp
Bank Municipal Securities Dealer Address

City

State

Zip Code

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.
Board of Governors of the Federal Reserve System
Risk Policy Section
Mail Stop 1810
20th and C Streets, NW
Washington, DC 20551
Federal Deposit Insurance Corporation
Policy & Program Development Section
550 17th Street, NW, Room MB-5100
Washington, DC 20429
The Office of the Comptroller of the Currency
Credit & Market Risk Division, (MS 7W-3)
400 7th Street, SW
Washington, DC 20219

06/2015