Form SEC 122 SEC 122 Form BDW

OMB APPROVAL

Form BDW

OMB Number:
3235-0018
Expires:
August 31, 2014
Estimated average burden
hours per response. . . . . . . . . . . . 0.25

Uniform Request
for
Broker-Dealer Withdrawal

SEC 122(04-07)

Persons who 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.

FORM BDW INSTRUCTIONS

A. GENERAL INSTRUCTIONS
1. Broker-Dealers must file Form BDW to withdraw their registration from the Securities and Exchange Commission (“SEC”),
Self-Regulatory Organizations (“SROs”), and appropriate jurisdictions. These instructions apply to filing Form BDW electronically with the Central Registration Depository (“CRD”). Some jurisdictions may require a separate paper filing of Form BDW
and/or additional filing requirements. Thus, the applicant should contact the appropriate jurisdictions(s) for specific filing
requirements.
2. All questions must be answered and all fields requiring a response must be complete before the filing is accepted. If filing
Form BDW on paper, enter “None” or “N/A” where appropriate.
3. File Form BDW with the CRD, operated by the NASD. Prior to filing Form BDW, amend Form BD to update any incomplete or
inaccurate information.
4. A paper copy of this Form BDW (or a reproduction of this form printed off the CRD), the original manual signature(s), must be
retained by the broker-dealer filing the Form BDW and be made available for inspection upon a regulatory request. A paper
copy of the initial Form BD filing and amendments to Disclosure Reporting Pages (DRPs BD) also must be retained by the
broker-dealer filing the Form BDW.
B. FULL WITHDRAWAL (terminates registration with the SEC, all SROs, and all jurisdictions):
1. Complete all items except Item 3.
2. If Item 5 is answered “yes,” file with the CRD a paper copy of FOCUS Report Part II (or Part IIA for non-carrying or nonclearing firms) “Statement of Financial Condition” and “Computation of Net Capital” sections. For firms that do not file FOCUS
Reports, file a statement of financial condition giving the type and amount of the firm’s assets and liabilities and net worth.
This information must reflect the finances of the firm no earlier than 10 days before this Form BDW is filed.
C. PARTIAL WITHDRAWAL (terminates registration with specific jurisdictions and SROs, but does not terminate registration with the
SEC and at least one SRO and jurisdiction):
1. Complete all items.
2. Check with jurisdiction(s) where registered for additional filing requirements.
The CRD mailing address for questions and correspondence is:
NASAA/NASD Central Registration Depository

P. O. Box 9495

Gaithersburg, MD 20898-9495

EXPLANATION OF TERMS

(The following terms are italicized throughout this form.)

The term JURISDICTION means a state, the District of Columbia, the Commonwealth of Puerto Rico, the U.S. Virgin Islands, or any
subdivision or regulatory body thereof.
The term INVESTIGATION includes: (a) grand jury investigations, (b) U.S. Securities and Exchange Commission investigations after
the “Wells” notice has been given, (c) NASD Regulation, Inc. investigations after the “Wells” notice has been given or after a person
associated with a member, as defined in The NASD By-Laws, has been advised by the staff that it intends to recommend formal
disciplinary action or, (d) formal investigations by other SROs or, (e) 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, 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, or savings association).

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 15, 15C, 17(a) and 23(a) of the Securities Exchange Act of 1934 authorize
the Commission to collect the information on this form from registrants. See 15 U.S.C. §§ 78o, 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 permit a broker-dealer to withdraw its registration. The Form also is used by broker-dealers to advise certain selfregulatory organizations and all of the states that they want to withdraw from registration. The Commission and the National
Association of Securities Dealers, Inc. maintain files 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 the application facing page of this Form, and any suggestions for 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.

Page 1

FORM BDW

OFFICIAL USE

UNIFORM REQUEST FOR WITHDRAWAL FROM
BROKER-DEALER REGISTRATION

WARNING: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT MAY C ONSTITUTE CRIMINAL VIOLATIONS.
1. A. FULL NAME OF BROKER-DEALER (if sole proprietor, state last, first and middle name):

B. IRS Emp. Ident. No.:

C. NAME UNDER WHICH BUSINESS IS CONDUCTED, IF DIFFERENT:
E. SEC FILE NO.:

F. FIRM MAIN ADDRESS:

G. MAILING ADDRESS, IF DIFFERENT:

4.

NUMBER AND STREET

NUMBER AND STREET

CITY

Full Withdrawal (skip item 3)

STATE/COUNTRY

ZIP+4/POSTAL CODE

H. AREA CODE / TELEPHONE NO.:

Partial Withdrawal (Check box(es) where withdrawing in Item 3.)

___________________________
AMEX

BSE

CBOE

CHX

NSX

NASD

NQX

NYSE

PHLX

ARCA

ISE

OTHER (specify)

Alabama

Hawaii

Michigan

North Carolina

Texas

Alaska

Idaho

Minnesota

North Dakota

Utah

Arizona

llinois

Mississippi

Ohio

Vermont

Arkansas

Indiana

Missouri

Oklahoma

Virgin Islands

California

Iowa

Montana

Oregon

Virginia

Colorado

Kansas

Nebraska

Pennsylvania

Washington

Connecticut

Kentucky

Nevada

Puerto Rico

West Virginia

Delaware

Louisiana

New Hampshire

Rhode Island

Wisconsin

District of Columbia

Maine

New Jersey

South Carolina

Wyoming

Florida

Maryland

New Mexico

South Dakota

Georgia

Massachusetts

New York

Tennessee

Date firm ceased business or withdrew registration request (for partial withdrawals,
give the date ceased business in the jurisdictions checked in item 3):

MM

DD

YYYY

/
YES

5.

CITY

SECURITIES AND EXCHANGE COMMISSION (check only if intending to conduct an intrastate business)

JURISDICTION

SRO SEC

2. Check One:
3.

D. FIRM CRD NO.:

/

NO

Does the broker-dealer owe any money or securities to any customer or broker-dealer?
If partial withdrawal, indicate jurisdiction(s) from which you are withdrawing
where you owe funds or securities to customers in such jurisdiction(s):

,

,

.

If full withdrawal, complete A-D below.
A. Number of customers owed funds or securities:
B. Amount of money owed to:

customers $

broker-dealers $

C. Market value of securities owed to:
customers $
broker-dealers $
D. Describe arrangements made for payment:
______________________________________________________________________________________________________
If this is a full withdrawal and Item 5 is answered “yes,” file with the CRD a FOCUS Report Part II (or Part IIA for non-carrying or non-clearing firms)
“Statement of Financial Condition” and “Computation of Net Capital” sections. For firms that do not file FOCUS Reports, file a statement of financial
condition giving the type and amount of the firm’s assets and liabilities and net worth. The FOCUS Report and the statement of financial condition must
reflect the finances of the firm no earlier than 10 days before this Form BDW is filed.
6.

Is the broker-dealer now the subject of or named in any investment-related:

YES

NO

 investigation
 consumer-initiated complaint
 private civil litigation

NOTE: Update any incomplete or inaccurate information contained in item 11 of Form BD.
7.

NAME AND ADDRESS OF THE PERSON WHO WILL HAVE CUSTODY OF BOOKS AND RECORDS:

ADDRESS WHERE BOOKS AND RECORDS WILL BE LOCATED, IF DIFFERENT:

8.

AREA CODE / TELEPHONE NO.:

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 broker-dealer, and that all
information herein, including any attachments hereto, is accurate, complete, and current. The undersigned and broker-dealer further certify that all
information previously submitted on Form BD is accurate and complete as of this date, and that the broker-dealer’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

Subscribed and sworn before me this _____________ day of _________________________ , ____________ by ___________________________________
Year

My Commission expires ___________________________

County of __________________________

Notary Public

State of ________________________________