G-405 PART III Report on Finances and Operations of Government Securiti

U.S. Department of the Treasury
Washington, D.C. 20220
ANNUAL AUDITED REPORT
FORM G-405
PART III

OMB APPROVAL
OMB # 1530-0064

Information Required of Government Securities
Brokers and Dealers
Pursuant to Section 15C of the Securities
Exchange Act of 1934, SEC Rule 17a-5 and 17 CFR 405.2

SEC FILE NUMBER

8-

AND ENDING

REPORT FOR THE PERIOD BEGINNING

MMDDYYYY

MMDDYYYY

A. REGISTRANT IDENTIFICATION
NAME OF GOVERNMENT SECURITIES BROKER OR DEALER:

OFFICIAL USE ONLY

FIRM ID. NO.

ADDRESS OF PRINCIPAL PLACE OF BUSINESS:
(Do not use P.O. Box No.)

(No. and Street)

(State)

(City)

(Zip Code)

NAME AND TELEPHONE NUMBER OF PERSON TO CONTACT IN REGARD TO THIS REPORT

(Area Code - Telephone No.)

B. ACCOUNTANT IDENTIFICATION
INDEPENDENT PUBLIC ACCOUNTANT whose opinion is contained in this Report *
(Name - if individual, state last, first, middle name)

(Address)

(City)

(State)

(Zip Code)

CHECK ONE:
Certified Public Accountant
Public Accountant
Accountant not resident in United States or any of its possessions

FOR OFFICIAL USE ONLY

*

SEC 1410 (11-84)

Claims for exemption from the requirement that the annual report be covered by the opinion of an
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)(2), 17 CFR 405.2)

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OATH OR AFFIRMATION
I,
, swear (or affirm) that, to the best of my
knowledge and belief the accompanying financial statement and supporting schedules pertaining to the firm of
, as of
in the year
,
are 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)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(j)

(k)
(l)
(m)

Facing page.
Statement of Financial Condition.
Statement of Income (Loss).
Statement of Changes in Financial Condition.
Statement of Changes in Stockholders’ Equity or Partners’ or
Sole Proprietor’s Capital.
Statement of Changes in Liabilities Subordinated to Claims of Creditors.
Computation of Capital.
Computation for Determination of Reserve Requirements Pursuant
to SEC Rule 15c3-3 and 17 CFR 403.4.
Information Relating to the Possession or Control Requirements
under SEC Rule 15c3-3 and 17 CFR 403.4
A Reconciliation, including appropriate explanation, of the Computation
of Capital Under 17 CFR 402.2 and the Computation for
Determination of the Reserve Requirements Under Exhibit A
if SEC Rule 15c3-3.
A Reconciliation between the audited and unaudited Statements of
Financial Condition with respect to methods of consolidation.
An Oath or Affirmation.
A report describing any material inadequacies found to exist or found
to have existed since the date of the previous audit.

* * For conditions of confidential treatment of certain portions of this filing, see
17 CFR 240.17a-5(e)(3), 17 CFR 405.2.

Public reporting burden for this collection of information is estimated to average 12 hours
per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any aspect of this collection of
information, including suggestions for reducing this burden to: Bureau of the Fiscal Service,
Government Securities Regulations Staff, 3201 Pennsy Drive, Building E, Landover, MD
20785-1603; and to the Office of Management and Budget, (1530-0064) Washington, DC 20503.

Form G-405 Part III

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