Form SBSE-W Form SBSE-W Form SBSE-W

Form SBSE-W

OMB Approval
OMB Number:
Expires:

3235-0696
January 31, 2019

Estimated average burden
per response:

1 hour

Request for Withdrawal from
Registration as a
Security-based Swap Dealer or
Major Security-based Swap
Participant

SEC 2928 (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-W INSTRUCTIONS

A.

GENERAL INSTRUCTIONS
1. Security-based swap dealers and major security-based swap participants (collectively “SBS Entities”) must file Form SBSE-W
to withdraw their registration from the Securities and Exchange Commission (“SEC”).
2. All questions must be answered and all fields requiring a response must be complete before the filing is accepted.
3. The registrant must file Form SBSE-W through the EDGAR system, and must utilize the EDGAR Filer Manual (as defined in
17 CFR 232. 11) to file and amend Form SBSE-W electronically to assure the timely acceptance and processing of those
filings. Prior to filing Form SBSE-W, amend Form SBSE, Form SBSE-A, or Form SBSE-BD, as applicable, in accordance with
Rule 15Fb2-3 [17 CFR 240.15Fb2-3], to update any incomplete or inaccurate information.
4. A paper copy of this Form SBSE-W with the original manual signature(s) must be retained by the security-based swap dealer
or major security-based swap participant filing the Form SBSE-W and be made available for inspection upon a regulatory
request. A paper copy of the initial Form SBSE, Form SBSE-A, or Form SBSE-BD filing, as appropriate, and amendments to
any Disclosure Reporting Pages (DRPs) also must be retained by the security-based swap dealer and major security-based
swap participant filing the Form SBSE-W.

The mailing address for questions and correspondence is:
The Securities and Exchange Commission

Washington, DC 20549

EXPLANATION OF TERMS

(The following terms are italicized throughout this form.)

The term INVESTIGATION includes: (a) grand jury investigations, (b) U.S. Securities and Exchange Commission investigations
after the “Wells” notice has been given, (c) formal investigations by a self-regulatory organization or, (d) actions or procedures
designated as investigations by jurisdictions. The term investigation does not include subpoenas, preliminary or routine regulatory
inquiries or requests for information, deficiency letters, “blue sheet” requests or other trading questionnaires, or examinations.
The term INVESTMENT-RELATED pertains to securities, commodities, banking, savings association activities, credit union
activities, insurance, or real estate (including, but not limited to, acting as or being associated with a broker-dealer, municipal
securities dealer, government securities broker or dealer, issuer, investment company, investment adviser, futures sponsor, bank,
savings association, credit union, insurance company, or insurance agency).

FEDERAL INFORMATION LAW AND REQUIREMENTS – SEC’s Colllection 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-10, 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 necessary or appropriate in the public interest or for the protection of
investors to permit the security-based swap dealer or major security-based swap participant to withdraw its registration. 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-W

Official Use

Request for Withdrawal from Registration as a
Security-based Swap Dealer or Major Security-based
Swap Participant

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

NOTE: Prior to filing a notice of withdrawal from registration on Form SBSE-W, an entity must update any incomplete or
inaccurate information contained on Form SBSE, Form SBSE-A, or Form SBSE-BD, as appropriate [17 CFR 15Fb32(a)].
1. A. Full name of Security-based Swap Dealer or Major Security-based Swap Participant:

B. IRS Emp. Ident. No.:

C. Name under which business is conducted, if different:
E. Firm main address: Number and Street
F. Mailing address, if different:

City

Number and Street

2. Withdrawing from Registration as a:

D. Firm SEC, NFA, and/or CRD No.:
State/Country

Zip+4/Postal Code

City

G. Area Code / Telephone No.:

[ ] Security-based Swap Dealer

[ ] Major Security-based Swap Participant
MM

3. Date firm ceased business:

DD
/

YY
/

4. Reason security-based swap dealer or major security-based swap participant is seeking to withdraw from SEC registration:
[ ] Winding down all business
[ ] No longer doing security-based swap business in U.S.
[ ] Have effected less security-based swap business for
previous four quarters and no longer fit definition of major
security-based swap participant

[ ] Ceasing business as a security-based swap dealer
[ ] Ceasing business as a major security-based swap
participant
[ ] Other (describe):
________________________________________________
Yes No

[ ] [ ]
5. Does the security-based swap dealer or major security-based swap participant hold any segregated counterparty collateral?
A. Number of counterparties whose collateral is held:
B. Amount of money held as collateral:
$
C. Market value of securities held as collateral:
$
D. Describe arrangements made for return of collateral:
__________________________________________________________________________________________________
yes
no
6. Is the security-based swap dealer or major security-based swap
investigation
[
]
[
]
participant currently the subject of or named in any investment-related:

- customer-initiated complaint
- private civil litigation
7. Name and Address of the Person who will have Custody of Books and Records:

[ ]
[ ]

[ ]
[ ]

Area Code / Telephone No.:

Address where the Books and Records will be Located, if Different: Number and Street City State/Country ZIP + 4/Postal Code
EXECUTION: The undersigned certifies that he/she has executed this form on behalf of, and with the authority of, the security-based swap dealer or securitybased swap participant, and that all information herein, including any attachments hereto, is accurate, complete, and current. The undersigned and security-based
swap dealer or major security-based swap participant further certify that all the information previously submitted on Form SBSE, Form SBSE-A, or Form SBSE-BD,
as appropriate, is accurate and complete as of this date, and that the security-based swap dealer’s or major security-based swap participant’s books and records
will be preserved and available for inspection as required by law.

Date (MM/DD/YYYY)

Name

By:
Signature

Print Name and Title