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 May 31, 2019
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 July 31, 2019
Page 1 of 3

Board of Governors of the Federal Reserve System
Federal Deposit Insurance Corporation
Office of the Comptroller of the Currency

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

PRIVACY ACT NOTICE
The Federal Reserve Board is authorized to request this information from you by Sections 3, 15B(c), 15C, 17 and 23 of Securities Exchange Act of
1934 (15 U.S.C. 78c, 78o-4, 78o-5, and 78q and 78w); and Section 11 of the Federal Reserve Act (12 U.S.C. 248). The purpose for collecting the
information is to comply with the registration requirements of municipal securities dealers, municipal securities representatives, and U.S. Government
securities brokers or dealers and associated persons contained in the Securities Exchange Act of 1934, and to support the Board’s regulatory and
supervisory functions. Furnishing the requested information is mandatory. Failure to provide the requested information in whole or in part may delay
or prohibit the determination of your compliance with applicable registration and professional qualification requirements. The information you provide
is protected by the Privacy Act, 5 U.S.C. 552(a). The information may be furnished to third parties as authorized by law and used according to any of
the routine uses described in the Municipal or Government Securities Principals and Representatives System of Records (BGFRS-17), available at
https://www.gpo.gov/fdsys/pkg/PAI-2013-BGFRS/xml/PAI-2013-BGFRS.xml#bgfrs17. If you have any questions or concerns about the collection
or use of the information, your may contact the Secretary of the Board, Board of Governors of the Federal Reserve System, 20th Street and
Constitution Avenue, NW, Washington, DC 20551.

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 Currenc , Washington, DC 20219.

03/2017

Form MSD-5
Page 2 of 3

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, enter “N/A”)

3. Not Applicable.

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

Government Securities

4. Bank Municipal Securities Dealer:

5. Office of Employment Address:

A.
Name

Street Address

Registration Number

City

B.
C.

State

Zip Code

6. Date Terminated:
Main Street Address

City

State

Zip Code

Month/Day/Year

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

Resigned*

Deceased

Other*

*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 t
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 (MM/DD/YYYY)

Person to contact for further information:
Name

Street Address

City

State

Zip Code

Area Code / Phone Number
03/2017

Acknowledgment for:

Form MSD-5

Form MSD-5
Page 3 of 3

Form G-FIN-5

10.
Name of Person Terminated

11.
Bank Municipal Securities Dealer Name

Receipt Stamp

12.
Bank Municipal Securities Dealer Address

City

13.

State

Zip Code

Attention

When the Form MSD-5 is received by the appropriate regulatory agency, this acknowledgment will be stamped to show
receipt and returned to the person named in item 13. The stamped acknowledgment should be retained to substantiate filing.

MAIL THE FORM TO THE REGULATOR INDICATED IN ITEM 9.
Board of Governors of the Federal Reserve System
Submit completed forms in Portable Document Format (PDF) to the Federal Reserve’s secure e-mail address:
[email protected]
Federal Deposit Insurance Corporation
Submit completed forms in Portable Document Format (PDF) to the Federal Deposit Insurance Corporation’s
secure e-mail address: [email protected]
or alternatively, mail the form and any attachments to:
Federal Deposit Insurance Corporation
Policy & Program Development Section

550 17th Street, NW, Room MB-5100

Washington, D.C. 20429

The Office of the Comptroller of the Currency
Upload completed forms via the OCC’s BankNet website www.banknet.gov
For assistance call (202) 649-6360

03/2017