6200/54 Form MSD-4 Uniform Application for Municipal Securities

FDIC OMB No. 3064-0022; Expiration Date: 06/30/2024
FRB OMB No. 7100-0100; Expiration Date: 07/31/2022
OCC OMB No. 1557-0184; Expiration Date: 09/30/2022

Federal Deposit Insurance Corporation

FORM MSD-4
UNIFORM APPLICATION FOR MUNICIPAL SECURITIES PRINCIPAL OR
MUNICIPAL SECURITIES REPRESENTATIVE ASSOCIATED WITH A BANK
MUNICIPAL SECURITIES DEALER
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 Office
of Management and Budget (OMB) control number. The information provided by each respondent is considered to be confidential.

FEDERAL DEPOSIT INSURANCE CORPORATION PRIVACY ACT NOTICE
The FDIC is authorized to request this information from you by Sections 15B(c), 15C, 17 and 23 of the Securities Exchange Act of 1934 (15 U.S.C.
78o-4, 78o-5, and 78q and 78w); and Section 9 of the Federal Deposit Insurance Act (12 U.S.C. 1819). 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 FDIC'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 qualifications requirements. The information you provide is protected by
the Privacy Act, 5 USC 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 Professional Qualification Records for Municipal Securities Dealers, Municipal Securities Representatives, and U.S. Government
Securities Brokers/Dealers System of Records (30-64-0016) available at www.fdic.gov/about/privacy/index.html. If you have questions or concerns
about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at [email protected].

BOARD OF GOVERNORS OF THE FEDERAL RESERVE SYSTEM 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 the 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 as described in the system of Records entitled BGFRS-17” FRB --Municipal or Government Securities Principals or Representatives,”
available at https://www.federalreserve.gov/files/BGFRS-17-municipal-or-government-securities-principals-and-representatives.pdf. If you have any
questions or concerns about the collection or use of the information, you may contact the Secretary of the Board, Board of Governors of the Federal
Reserve System, 20th Street and Constitution Avenue, NW, Washington, DC 20551.

OFFICE OF THE COMPTROLLER OF THE CURRENCY PRIVACY ACT NOTICE
The Office of the Comptroller of the Currency is authorized to request this information from you by 12 U.S.C. 1, 481, 1464, 1818, and 1820; 15 U.S.C.
78o-4, 78o-5, 78q, and 78w. The purpose of collecting the information is for the OCC to carry out its responsibilities under the federal securities laws
relating to the professional qualifications and fitness of individuals who engage or propose to engage in securities activities on behalf of national banks,
federal savings associations, and District of Columbia savings associations operating under the OCC's regulatory authority. Failure to provide the
requested information in whole or in part may delay or prevent 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 Bank Securities Dealers System --Treasury/Comptroller
system of record notice (Treasury/CC .210) available at https://www.federalregister.gov/documents/2016/01/19/2016-00763/privacy-act-of-1974-asamended-system-of-records. If you have any questions or concerns about the collection or use of the information, you may contact the Deputy
Comptroller, Market Risk Division, Office of the Comptroller of the Currency, 400 Seventh St S.W., Suite 7W-215, Washington D.C. 20219.
PAPERWORK REDUCTION ACT NOTICE
Public reporting burden for this collection of information is estimated to average 1 hour 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 the Paperwork Reduction Act Clearance Officer, Legal
Division, Federal Deposit Insurance Corporation, 550 17th Street, N.W., Washington, D.C. 20429, and the Office of Management and Budget,
Paperwork Reduction Project (3064-0022) Washington, DC 20503.
Page down to access form FDIC 6200/54

FDIC 6200/54 (6-21)

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FDIC OMB No. 3064-0022; Expiration Date: 06/30/2024
FRB OMB No. 7100-0100; Expiration Date: 07/31/2022
OCC OMB No. 1557-0184; Expiration Date: 09/30/2022

Federal Deposit Insurance Corporation

Submit

FORM MSD-4
UNIFORM APPLICATION FOR MUNICIPAL SECURITIES PRINCIPAL OR
MUNICIPAL SECURITIES REPRESENTATIVE ASSOCIATED WITH A BANK
MUNICIPAL SECURITIES DEALER
INSTRUCTIONS: For complete instructions, see form FDIC 6200/54i, Instructions for MSD-4 Uniform Application for Municipal Securities Principal or
Municipal Securities Representative Associated with a Bank Municipal Securities Dealer. This form may be completed electronically and submitted to
the Federal Deposit Insurance Corporation using the Submit button above to the right. By selecting the Submit button, the form will be emailed to
[email protected] for processing. If you wish to print the form to mail your submission, select the Set Form to Print button above to
the left and all hidden fields will be expanded and additional lines will appear for questions 7, 17, and 18. Once printed and completed, the form should
be mail to the Federal Deposit Insurance Corporation, Division of Consumer Protection, Policy and Program Development Section, Room F-6044, 550
17th Street, NW, Washington, DC 20429.
SECTION I - GENERAL INFORMATION
1. Name (Last, First, MI)

2. Bank Municipal Securities Dealer
a. Name

b. Registration Number

c. Address (Street, City, State, and ZIP Code)

3. Office of Employment of Applicant

5. To be filed with:

4. Date of Employment with MSD

Federal Deposit Insurance Corporation

Board of Governors of the Federal Reserve

Comptroller of the Currency

SECTION II - QUALIFICATIONS
6. Type(s) of Qualification Requested (Select all that apply):
Municipal Securities Representative

Government Securities Representative

Municipal Securities Principal

Government Securities Supervisor

7. It is anticipated that the applicant will perform the following functions in the capacity indicated (Select all that apply):
Capacity
Supervisory

Non-Supervisory

a. Underwriting, trading or sales of municipal securities.............................................................................
b. Financial advisory or consultant services for issuers in connection with the issuance of municipal
securities.................................................................................................................................................
c. Research or investment advice with respect to municipal securities in connection with the activities
described in items 7a and 7b above.....................................................................................................
d. Activities other than those specifically mentioned that involve communication directly or indirectly with
public investors in municipal securities in connection with the activities described in items 7a and 7b
above......................................................................................................................................................
e. Processing and cleaning activities with respect to municipal securities.................................................

N/A

f. Maintenance of records involving activities described in items 7a through 7e above...........................

N/A

g. Training of municipal securities principals or municipal securities representatives................................

N/A

SECTION III - VERIFICATION
8. For the purpose of verifying the information furnished on this application by the applicant named in item 1 above, this institution has made inquiry of
all employers of the applicant during the immediately preceding three years, as set forth below, concerning the accuracy and completeness of the
information provided, and concerning the record and reputation of the applicant as related to the ability to perform the duties for which employed or
to be employed.
Add

Remove

+

-

Employer

Name of Person Contacted

Position of Person Contacted

SECTION IV - MUNICIPAL SECURITIES PRINCIPAL AUTHORIZATION
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. sections 1001 and 1005, and 15 u.s.c. 78ff.)
9. Date

FDIC 6200/54 (6-21)

10. Name

11. Signature

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FDIC OMB No. 3064-0022; Expiration Date: 06/30/2024
FRB OMB No. 7100-0100; Expiration Date: 07/31/2022
OCC OMB No. 1557-0184; Expiration Date: 09/30/2022
SECTION V - PERSONAL HISTORY OF APPLICANT
12. Name (Last, First, MI)

13. Social Security Number (Optional)

14. Address (Street, City, State, and ZIP Code):

15. Any other name ever used or by which known:
16. EMPLOYMENT AND EDUCATION HISTORY. The following is a complete, consecutive statement of all my employment for the past ten years
starting with my immediately previous employer. (Include full- and part-time work, self-employment, military service, unemployment, and full-time
education). For each period of employment, list the position held at the time of leaving employment.

Add

Remove

+

-

Employer Name

Type of Business

From Date

To Date

Position Held

Reason For Leaving

Full-Time or
Part-Time

17. RESIDENTIAL HISTORY. The following is a complete, consecutive statement of all my residential addresses for the past five years starting with
my current residence:
Add

Remove

+

-

Address (Street, City, State, ZIP Code, and Country)

From Date

To Date

18. a. Have you ever taken a qualification examination for municipal securities principals, municipal securities representatives, or financial and
Yes
No
operations principals prescribed by the Municipal Securities Rulemaking Board?
If yes, state below the type of examination and the approximate date taken.
Type of Examination:

Approximate Date:

Type of Examination:

Approximate Date:

b. Have you ever been exempt from or received a waiver of the requirement to take and pass an examination of the nature specified in Question
19.a?
Yes
No
If yes, state below the type of examination, the basis for such exemption or waiver, and, in the case of a waiver, the approximate date.
Type of Examination:

Basis for Exemption or Waiver Approximate Date:

Type of Examination:

Basis for Exemption or Waiver Approximate Date:

19. Are you currently bonded?

Yes

No

20. Have you ever been refused coverage under a fidelity bond or has any surety company paid out any funds on your coverage or cancelled such
Yes
No
coverage?
If Yes, explain.

21. Have you ever been denied membership, registration, license, permit, or certification by any federal or state securities or federal or state bank
regulatory agency, any national securities exchange, registered securities association, or registered clearing agency?
Yes
No
If Yes, explain.

22. Has any disciplinary action ever been taken against you, or any sanction imposed upon you, including any finding that you were a cause of any
disciplinary action or violated any law, rule or regulation or were an aider, abettor, or co-conspirator in any such violation, by any federal or state
securities or federal or state bank regulatory agency, any national securities exchange, registered securities association, or registered clearing
Yes
No
agency?
If Yes, explain.

23. While you were associated in any capacity with any broker, dealer or municipal securities dealer:
Yes
No
a. Was your registration denied, suspended or revoked?
If Yes, explain.

FDIC 6200/54 (6-21)

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FDIC OMB No. 3064-0022; Expiration Date: 06/30/2024
FRB OMB No. 7100-0100; Expiration Date: 07/31/2022
OCC OMB No. 1557-0184; Expiration Date: 09/30/2022
b. Was your membership in any national securities exchange, registered securities association, or registered clearing agency denied, suspended,
or revoked, or was it expelled from any such organization?
Yes
No
If Yes, explain.

24. Has any permanent or temporary injunction (including a cease and desist order) ever been entered against you enjoining conduct as an
investment advisor, underwriter, broker, dealer or municipal securities dealer or as an affiliated person of any investment company, bank dealer, or
municipal securities dealer or as an affiliated person of any investment company, bank, insurance company, or enjoining any conduct related to
Yes
No
such activities or any transactions in any security?
If Yes, explain.

25. Have you been convicted within the past ten years of any felony or misdemeanor: (i) involving the purchase or sale of any security, the taking of a
false oath, the making of a false report, bribery, perjury, burglary, or conspiracy to commit any such offense; (ii) arising out of the conduct of the
business of a broker, dealer, municipal securities dealer, investment adviser, bank, insurance company, or fiduciary; (iii) involving larceny, theft,
robbery, extortion, forgery, counterfeiting, fraudulent concealment, embezzlement, fraudulent conversion, or misappropriation of funds or
securities; (iv) involving crimes of concealment of assets, false oaths or claims, bribery in a bankruptcy proceeding, mail fraud, fraud by wire
(including telephone, telegraph, radio, or television), fraud or false statements?
Yes
No
If Yes, explain.

26. Signature of Applicant

27. Date

SECTION VI - ACKNOWLEDGMENT
28. Acknowledgment for:

Form MSD-4

Form G-FIN-4

29. Applicant Name:
30. Bank Municipal Securities Dealer Name:

Receipt Stamp

31. Bank Municipal Securities Dealer Address:
32. Attention:
WHEN THE FORM MSD-4 IS RECEIVED, THIS ACKNOWLEDGMENT WILL BE STAMPED TO SHOW RECEIPT AND
RETURNED TO THE PERSON NAMED IN ITEM 32. THE STAMPED ACKNOWLEDGMENT SHOULD BE RETAINED TO
SUBSTANTIATE FILING.

Print to Submit Form

MAIL THE FORM TO THE REGULATOR INDICATED IN ITEM 5.

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 F-6044
Washington, D.C. 20429
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]
The Office of the Comptroller of the Currency
Upload completed forms via the OCC's BankNet website www.banknet.gov
For assistance call (202) 649-6438

FDIC 6200/54 (6-21)

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