Information Collection

Disclosure Form for Person Associated with a Financial Institution Securities Broker or Dealer

IC 235136 under ICR 202306-3064-004 · OMB 3064-0093.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3064-0093 can be found here:

2025-03-28 - Extension without change of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form G-FIN-4 Disclosure Form for Person Associated with a Financial Institution Securities Broker or Dealer	Form and Instruction
G-FIN-4 Disclosure Form for Person Associated with a Financial I G-FIN-4.pdf	Form and Instruction
G-FIN-4 Disclosure Form for Person Associated with a Financial I G-FIN-4.pdf	Form and Instruction
Justification Memo Non Substantive Revisions 3064-0093 June 2023.docx Justification Memo for Non-Substantive Revision June 2023	IC Document
Justification Memo Non Substantive Revisions 3064-0093 June 2023.docx Justification Memo for Non-Substantive Revision June 2023	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Disclosure Form for Person Associated with a Financial Institution Securities Broker or Dealer

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 17 CFR Part 401 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	G-FIN-4	Disclosure Form for Person Associated with a Financial Institution Securities Broker or Dealer	G-FIN-4.pdf		Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Economic Development

Subfunction: Financial Sector Oversight

Privacy Act System of Records

Title: Professional Qualification Records for Municipal Securities Dealers, Municipal Securities Representatives and U.S. Government Securities Broker/Dealers

FR Citation: 84 FR 35184

Number of Respondents: 1

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	5	5
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Justification Memo for Non-Substantive Revision June 2023	Justification Memo Non Substantive Revisions 3064-0093 June 2023.docx	06/08/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.