Form SBSE-C Form SBSE-C Form SBSE-C

Form SBSE-C

OMB Approval
OMB Number:
Expires:

3235-0696
January 31, 2019

Estimated average burden hours
per response:

41 hours

Certifications for
Registration of Security-based
Swap Dealers and Major Securitybased Swap Participants

SEC 2927 (1/16)

Persons who 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.

FORM SBSE-C INSTRUCTIONS

A. GENERAL INSTRUCTIONS
1. Each security-based swap dealer and major security-based swap participant must file Form SBSE-C to register as a
security-based swap dealer or major security-based swap participant.
2. ELECTRONIC FILING – The applicant must file Form SBSE-C through the EDGAR system, and must utilize the EDGAR
Filer Manual (as defined in 17 CFR 232. 11) to file and amend Form SBSE-C electronically to assure the timely
acceptance and processing of those filings.
3. All fields requiring a response must be complete before the filing is accepted.
The mailing address for questions and correspondence is:
The Securities and Exchange Commission

Washington, DC 20549

FEDERAL INFORMATION LAW AND REQUIREMENTS – SEC’s Collection of Information
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 control number. Sections 15F, 17(a) and 23(a) of the Exchange Act authorize the SEC to collect the information on
this form from registrants. See 15 U.S.C. §§78o, 78o-4, 78o-5, 78q and 78w. Filing of this Form is mandatory. The principal
purpose of this Form is to permit the Commission to determine whether it is in the public interest to approve or disapprove the
application for ongoing registration by the security-based swap dealer or major security-based swap participant. The Commission
maintains a file of the information on this Form and will make the information publicly available. Any member of the public may
direct to the Commission any comments concerning the accuracy of the burden estimate on this Form, and any suggestions for
reducing this burden. This collection of information has been reviewed by the Office of Management and Budget in accordance
with the clearance requirements of 44 U.S.C. §3507. The information contained in this Form is part of a system of records subject
to the Privacy Act of 1974, as amended. The Securities and Exchange Commission has published in the Federal Register the
Privacy Act Systems of Records Notice for these records.

FORM SBSE-C
Certification 1

Applicant Name: _________________________________
Date:__________

Official Use

SEC Filer No: _________

INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACTS MAY CONSTITUTE FEDERAL CRIMINAL VIOLATIONS.
See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a)

Instructions:

This Certification 1 must be signed by a senior officer of the applicant.

I certify that (1) after due inquiry, I have reasonably determined that the applicant has developed and implemented written policies and
procedures reasonably designed to prevent violation of federal securities laws and the rules thereunder, and
(2) I have documented the process by which I reached such determination.

Applicant Name:

Date:

Signature of Senior Officer:

Name of Senior Officer:
Title of Senior Officer

FORM SBSE-C
Certification 2

Applicant Name: _________________________________
Date:__________

Official Use

SEC Filer No: __________

INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACTS MAY CONSTITUTE FEDERAL CRIMINAL VIOLATIONS.
See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a)

Instructions:

This certification must be signed by the applicant’s Chief Compliance Officer designated pursuant to Exchange
Act Section 15F(k) or by his or her designee.
For purposes of this Form, the term associated person shall have the meaning as specified in Section 3(a)(70) of
the Exchange Act [15 U.S.C. 78c(a)(70)].

The applicant certifies that it (a) has performed background checks on all of its associated persons who are natural persons and who effect or are
involved in effecting security-based swaps on its behalf, and
(b) neither knows, nor in the exercise of reasonable care should have known, that any associated person who effects
or is involved in effecting security-based swaps on its behalf is subject to a statutory disqualification, as described
in Sections 3(a)(39)(A) through (F) of the Securities Exchange Act of 1934 (15 U.S.C. 78c(a)(39)(A) – (F)), unless
otherwise specifically provided by rule, regulation or order of the Commission.
Applicant Name:

Date:

Signature of Chief Compliance Officer or Designee:
Name of Chief Compliance Officer or Designee:

If Designee, Title of Designee: