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UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
AUDITED ANNUAL REPORT
FORM X‐17A‐5
PART III
SEC FILE NUMBER
FACING PAGE
Information Required Pursuant to Rules 17a‐5, 17a‐12, and 18a‐7 under the Securities Exchange Act of 1934
REPORT FOR THE PERIOD BEGINNING _____________________ AND ENDING _____________________
MM/DD/YY
MM/DD/YY
A. REGISTRANT IDENTIFICATION
NAME OF FIRM: _______________________________________________________________________
TYPE OF REGISTRANT (check all applicable boxes): ☐ OTC derivatives dealer
☐ Broker‐dealer ☐ Security‐based swap dealer ☐ Major security‐based swap participant
ADDRESS OF PRINCIPAL PLACE OF BUSINESS: (Do not use P.O. box no.)
_____________________________________________________________________________________
(No. and Street)
_____________________________________________________________________________________
(City)
(State)
(Zip Code)
NAME AND TELEPHONE NUMBER OF PERSON TO CONTACT WITH REGARD TO THIS REPORT
_____________________________________________________________________________________
(Name)
(Area Code – Telephone Number)
(Email Address)
B. ACCOUNTANT IDENTIFICATION
PCAOB‐REGISTERED INDEPENDENT PUBLIC ACCOUNTANT whose opinion is contained in this report*
_____________________________________________________________________________________
(Name – if individual, state last, first, and middle name)
_____________________________________________________________________________________
(Address)
(City)
(State)
(Zip Code)
_____________________________________________________________________________________
(Date of Registration with PCAOB)
FOR OFFICIAL USE ONLY
* Claims for exemption from the requirement that the annual report be covered by the opinion of a PCAOB‐registered
independent public accountant must be supported by a statement of facts and circumstances relied on as the basis of the
exemption. See 17 CFR 240.17a‐5(e)(1)(ii), if applicable.
Persons who are to respond to the collection of information contained in this form are not required to respond unless the
form displays a currently valid OMB control number.
OATH OR AFFIRMATION
I, ___________________________________________, swear (or affirm) that, to the best of my knowledge and belief, the
information
contained
in
the
audited
annual
report
pertaining
to
the
firm
of
____________________________________________________________, as of ______________________________, 20____,
is true and correct. I further swear (or affirm) that neither the company nor any partner, proprietor, principal officer, or
director has any proprietary interest in any account classified solely as that of a customer, except as follows: _______________
________________________________________________________________________________________________________
Signature: ____________________________________
Title: ________________________________________
______________________________
Notary Public
This report** contains (check all applicable boxes):
☐ (a) Facing page.
☐ (b) Statement of financial condition.
☐ (c) Statement of income (loss).
☐ (d) Statement of cash flows.
☐ (e) Statement of changes in stockholders’ equity or partners’ or sole proprietor’s capital.
☐ (f) Statement of changes in liabilities subordinated to claims of creditors.
☐ (g) Computation of net capital under 17 C.F.R. § 240.15c3‐1.
☐ (h) Computation of net capital under 17 C.F.R. § 240.18a‐1.
☐ (i) Computation of tangible net worth under 17 C.F.R. § 240.18a‐2.
☐ (j) Computation for determination of reserve requirements pursuant to Exhibit A to 17 C.F.R. § 240.15c3‐3.
☐ (k) Computation for determination of reserve requirements pursuant to Exhibit A to 17 C.F.R. § 240.18a‐4.
☐ (l) Information relating to possession or control requirements under 17 C.F.R. § 240.15c3‐3.
☐ (m) Information relating to possession or control requirements under 17 C.F.R. § 240.18a‐4.
☐ (n) A reconciliation, including appropriate explanation of the computation of net capital under 17 C.F.R. § 240.15c3‐1.
☐ (o) A reconciliation, including appropriate explanation of the computation of the reserve requirements under 17 C.F.R.
§ 240.15c3‐3.
☐ (p) A reconciliation, including appropriate explanation of the computation of net capital under 17 C.F.R. § 240.18a‐1.
☐ (q) A reconciliation, including appropriate explanation of the computation of tangible net worth under 17 C.F.R. § 240.18a‐2.
☐ (r) A reconciliation, including appropriate explanation of the computation of reserve requirements under 17 C.F.R. § 240.18a‐4.
☐ (s) A reconciliation between the audited and unaudited Statements of Financial Condition with respect to methods of
consolidation.
☐ (t) An oath or affirmation.
☐ (u) A copy of the SIPC Supplemental Report.
☐ (v) A report describing any material inadequacies found to exist or found to have existed since the date of the previous audit
under 17 C.F.R. § 240.17a‐12(k).
☐ (w) Exemption report in accordance with 17 C.F.R. § 240.17a‐5.
☐ (x) Compliance report in accordance with 17 C.F.R. § 240.17a‐5.
☐ (y) Compliance report in accordance with 17 C.F.R. § 240.18a‐7.
☐ (z) Independent public accountant’s report based on an examination of the financial report under 17 C.F.R. § 240.17a‐5.
☐ (aa) Independent public accountant’s report based on an examination of the financial statements under 17 C.F.R. § 240.17a‐12.
☐ (bb) Independent public accountant’s report based on an examination of the compliance report under 17 C.F.R. § 240.17a‐5.
☐ (cc) Independent public accountant’s report based on a review of the exemption report under 17 C.F.R. § 240.17a‐5.
☐ (dd) Independent public accountant’s report based on an examination of the financial report under 17 C.F.R. § 240.18a‐7.
☐ (ee) Independent public accountant’s report based on an examination of the compliance report under 17 C.F.R. § 240.18a‐7.
☐ (ff) Other: _______________________________________________________________________________________________
**To request confidential treatment of certain portions of this filing, see 17 C.F.R. § 240.17a‐5(e)(3) or 17 C.F.R. § 240.18a‐7(d)(2), as
applicable.
File Type | application/pdf |
File Title | Proposed Rule: Recordkeeping and Reporting Requirements for Security-Based Swap Dealers, Major Security-Based Swap Participants, |
Subject | 17 CFR Parts 240 and 249, Release No. 34-71958, File No. S7-05-14, RIN 3235-AL45, Date: 2014-04-17 |
Author | U.S. Securities and Exchange Commission |
File Modified | 2016-06-15 |
File Created | 2014-01-23 |