Deregistrations (Form TA-W)

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FR TA-W
OMB Number 7100-0099
Approval expires December 31, XXXX
Page 1 of 3

Board of Governors of the Federal Reserve System

Transfer Agent Deregistration—Form TA-W

Under section 17A(c)(4)(B) of the Securities Exchange Act of
1934 and the rules and regulations thereunder, a registered
transfer agent may, upon such terms and conditions as the
appropriate regulatory agency for such transfer agent deems
necessary or appropriate or in the public interest, for the protection of investors, withdraw from registration by filing a written
notice of withdrawal with such appropriate regulatory agency.

The information will be used for the principal purpose of determining whether the transfer agent's existing registration should
be canceled.
Information supplied on this form will be available for inspection
by any interested person.
An agency may not conduct or sponsor, and an organization (or a
person) is not required to respond to, a collection of information
unless it displays a currently valid OMB control number.

Public reporting for this collection of information is estimated to average 0.5 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 other aspect of this collection of information, including suggestions for reducing this burden, to: Secretary, Board of Governors of the Federal Reserve System, 20th and C Streets, NW, Washington, DC 20551; and to the Office
of Management and Budget, ATTN: Paperwork Reduction Project (7100-0099), Washington, DC 20503.

XX/2022

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For Official Use Only
Reg/File Number

Form TA-W
Page 2 of 3

Transfer Agent Deregistration—Continued
Please print or type all responses. Registrants submitting the information below must submit a Portable Document Format (“PDF”)
version of the form and attachments to the designated email address [email protected].
1. Full name of Registrant organization:
Full Name

2. Main Office Location of Registrant:
Street Address

City

State

Zip Code

3. Registrant transfer agent number:

8

-

4. Furnish registrant's reasons for ceasing the performance of transfer agent functions or for otherwise requesting withdrawal of
its registration:

5. Furnish the date on which the organization last transferred any securities for which registration would be required:
Date (MM/DD/YYYY)

6. Furnish the name(s) and location(s) of the organization or person, which will retain possession of the books and records which the
bank maintained for its registered transfer agent functions:
Name

Street Address

City

Name

Zip Code

State

Zip Code

State

Zip Code

Street Address

City

Name

State

Street Address

City

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Form TA-W
Page 3 of 3

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Transfer Agent Deregistration—Continued
7. Furnish the name(s) and location(s) of any successor transfer agent(s):
Name

Street Address

City

Name

State

Zip Code

State

Zip Code

State

Zip Code

Street Address

City

Name

Street Address

City

8. Describe any legal actions or proceedings, or potential claims against the bank, in connection with the performance of its registered
transfer agent functions:

9. Describe any unsatisfied judgements or liens against the bank arising out of performance of its registered transfer agent functions:

Execution: The Registrant submitting this form, and the person executing it, hereby represent that all the information contained
herein is true, correct, and complete.
Attention: Intentional misstatements or omissions of fact constitute federal criminal violations. See 18 U.S.C. 1001 and
15 U.S.C. 78ff(a).

10. Full name of official responsible for form (print or type):
First Name

Middle Name

10.a. Title of official responsible for form:
Title

11.
Last Name

Signature of Official Responsible for form

12.
Date (MM/DD/YYYY)

XX/2022