Form MSD-5 Uniform Termination Notice for Municipal Securities Prin

Board of Governors of the Federal Reserve System
OMB No. 7100-0101 Expires April 30, 2010
Federal Deposit Insurance Corporation
OMB No. 3064-0022 Expires December 31, 2011
Office of the Comptroller of the Currency
OMB No. 1557-0184 Expires May 31, 2010
Office of Thrift Supervision
OMB No. 1550-0123 Expires August 31, 2011

Form MSD-5
Uniform Termination Notice 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, the Office of the Comptroller of the
Currency, and the Office of Thrift Supervision are authorized to collect this
information pursuant to the authority contained in the following statutes:
15 U.S.C. sections 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.

REPORTING BURDEN: 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, N.W. Washington, DC
20551; or to Assistant Executive Secretary, Federal Deposit Insurance
Corporation, Washington, DC 20429; or to Legislative and Regulatory
Analysis Division, Office of the Comptroller of the Currency, Washington,
DC 20219, or to Managing Director, Examination and Supervision Policy,
Office of Thrift Supervision, 1700 G Street NW, Washington, DC 20552.

FORM MSD-5
Uniform Termination Notice for
Municipal Securities Principal or Municipal Securities Representative
Associated with a Bank Municipal Securities Dealer
1.

INDIVIDUAL’S NAME
Last

2.

First

CAPACITY (check all that apply):
Municipal Securities ............................................................................... G

3.

SOCIAL SECURITY NUMBER (optional)

4.

BANK MUNICIPAL SECURITIES DEALER:
A. NAME
B.

REGISTRATION NUMBER

C.

MAIN ADDRESS

5.

OFFICE OF EMPLOYMENT ADDRESS

6.

DATE TERMINATED

Middle (if none, write “n/a”)
Government Securities ................................................................G

Month
7.

Day

Year

REASON FOR TERMINATION (check one):
*RESIGNED .................................................................... G

DECEASED.........................................................................G

*DISCHARGED ............................................................... G

*OTHER . ............................................................................G

*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 the Securities Exchange Act of
1934) described in Rules G-4 and G-5 of the Municipal Securities Rulemaking Board?

**YES

G

NO

G

** FURNISH FULL DETAILS ON ATTACHED SHEET.

9.

TO BE FILED WITH THE FOLLOWING (check one):
Comptroller of the Currency
Office of Thrift Supervision

Date

G
G

Board of Governors of the Federal Reserve System

Print Name of Municipal
Securities Principal

G

Federal Deposit Insurance Corporation

G

Signature of Municipal
Securities Principal

PERSON TO CONTACT FOR FURTHER INFORMATION

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.)

1

Acknowledgement for
FORM MSD-5 G
FORM G-FIN-5 G

10. NAME OF PERSON TERMINATED
Last

First

Middle (if none, write “n/a”)
Return Receipt

11. Bank Municipal Securities Dealer Name

12. Bank Municipal Securities Dealer Address

13. Attention:

WHEN THE FORM MSD-5 IS RECEIVED BY THE APPROPRIATE REGULATORY AGENCY, THIS ACKNOWLEDGEMENT WILL BE STAMPED TO
SHOW RECEIPT AND RETURNED TO THE PERSON NAMED IN ITEM 13. THE STAMPED ACKNOWLEDGEMENT SHOULD BE RETAINED TO
SUBSTANTIATE FILING.

Mail the form to the Regulator indicated in item 9
The Office of the Comptroller of the Currency
Treasury and Market Risk (MS 7-1)
250 E. Street, S.W.
Washington, DC 20219
Board of Governors of the Federal Reserve System
Market and Liquidity Risk Section
Mail Stop 185
20th and C Streets, N.W.
Washington, DC 20551
Federal Deposit Insurance Corporation
Division of Supervision
Securities, Capital Markets, and Trust Branch
Room F-2052
550 17th Street, N.W.
Washington, DC 20429
Office of Thrift Supervision
Managing Director
Examination and Supervision Policy
1700 G Street NW
Washington, DC 20552

INSTRUCTIONS FOR COMPLETING AND FILING FORM MSD-5

GENERAL INSTRUCTIONS

1. As used in these instructions and Form MSD-5, the
term bank municipal securities dealer means a municipal
securities dealer that is a bank or a department or
division of a bank.
2. Form MSD-5 is intended for use by bank municipal
securities dealers in reporting the termination of a municipal securities principal's or municipal securities representative's association with such dealer.
3. Bank municipal securities dealers are required to file
Form MSD-5 with the appropriate regulatory agency as
set forth below:
a. A bank municipal securities dealer that is a state
member bank of the Federal Reserve System, a
department of any such bank, or a State branch or
agency of a foreign bank is required to file with the
Board of Governors of the Federal Reserve System.
b. A bank municipal securities dealer that is a bank
insured by the Federal Deposit Insurance Corporation (other than a Federal Reserve System member
bank) or a department or division of any such bank is
required to file with the Federal Deposit Insurance
Corporation.
c. A bank municipal securities dealer that is a
national bank or bank operating under the Code of
Law for the District of Columbia or a department or
division of any such bank is required to file with the
Comptroller of the Currency.
4. Copies of Form MSD-5 may be obtained from any
one of the regulatory agencies listed in instruction 3.
5. An original and one copy of Form MSD-5 and any
attachments are to be filed with the appropriate regulatory agency listed in instruction 3 within thirty days after
termination of the association with the individual named
in item 1. A bank municipal securities dealer filing Form
MSD-5 shall retain an exact copy in its records for at
least three years after the applicant's employment or
other association with such dealer has terminated.
6. If more space is needed to complete an answer, an
appropriate designation shall be entered in the answer
space provided, and one or more attachment sheets
shall be used to complete the response. All attachments
shall be submitted in the same format as the items to
which response is made and should be typed on white
8-1/2 x 11 in. paper. The answers to more than one
question may appear on an attachment sheet if the
questions are clearly identified. Attachments should be
paginated and the name of both the person terminated
and the bank municipal securities dealer should appear
on every attachment sheet.
7. Form MSD-5 and any attachments may be duplicated

by any method which produces legible copies of type
size identical to that of the Form MSD-5 on white 8-1/2 x
11 in. paper.
8. Form MSD-5 shall be manually signed on page 1
(bottom) by a municipal securities principal of the employing bank municipal securities dealer.
9. All items on Form MSD-5 must be completed, except
that disclosure of one's social security number is optional. The date on which Form MSD-5 is received by
the appropriate regulatory agency shall be the date of
filing. A Form MSD-5 that is not prepared and executed
in accordance with the applicable requirements may be
returned as unacceptable. Acceptance for filing shall not
constitute any finding that a Form MSD-5 has been
completed in accordance with those requirements or that
any information reported on the form is true, current,
complete, or not misleading.
10. Section 17(c)(1) of the Securities Exchange Act of
1934 requires every bank municipal securities dealer that
files any application, notice, report, or document with its
appropriate regulatory agency to file a copy of that
application, notice, report, or document with the
Securities and Exchange Commission (SEC). The SEC
and the appropriate regulatory agencies listed in instruction 3 have developed procedures under which the latter
will transmit a copy of any application, notice, report, or
document filed with them by a bank municipal securities
dealer to the SEC. Accordingly, when this form is filed
with the appropriate regulatory agency, it will be deemed
to have been filed with the SEC.
11. If this form is being filed in lieu of Form G-FIN-5,
check all applicable types of qualifications requested in
item 2.

PRIVACY ACT NOTICE FOR FORM MSD-5
(To Accompany Form MSD-5)

GENERAL
This information, in accordance with the Privacy Act
of 1974 (5 U.S.C. 552a), is provided to those
applicants completing Form MSD-5 (Uniform Termination Notice for Municipal Securities Principal or
Municipal Securities Representative Associated
with a Bank Municipal Securities Dealer), which is
to be filed with the appropriate regulatory agency,
as defined in section 3(a)(34) of the Securities
Exchange Act of 1934 [15 U.S.C. 78c(a)(34)].

2. To refer to the appropriate court, magistrate or
administrative law judge such information as may
be relevant to proceedings before any such court or
judicial officer.
3. To make use of such information as may aid in
the resolution of any action or proceeding:

AUTHORITY

a. in which the federal securities or banking
laws are at issue;

Sections 15B(c)(5), 17 and 23 of the Securities
Exchange Act of 1934 (15 U.S.C. 78o-4, 78q and
78u).

b. in which the propriety of any disclosure of
information reported on Form MSD-5 is at issue; or

PURPOSE

c. to which the appropriate regulatory agency
or a past or present member of its staff is a
party or otherwise involved in an official capacity.

The appropriate regulatory agency will review the
information reported on Form MSD-5 for the purpose of determining the reason for termination for
municipal securities principals and municipal securities representatives set forth in the General Rules
of the Municipal Securities Rulemaking Board.
EFFECTS OF NONDISCLOSURE
Bank municipal securities dealers whose association has terminated with an individual who was
employed by the dealer as a municipal securities
principal or representative are required to disclose
the information necessary to complete Form
MSD-5, except that disclosure of social security
numbers is optional. Dealers who do not disclose
the necessary information may be in violation of
applicable federal securities or banking laws and
thus may be subject to disciplinary action.
ROUTINE USES
The information reported in Form MSD-5 may be
routinely used by the appropriate regulatory agency
as follows:
1. To refer to the appropriate government authority, whether federal, state, local, or foreign, or to the
appropriate self regulatory organization (SRO),
such information as may indicate a violation or
potential violation of law, regulation or rule.

4. To disclose to a federal, state, local or foreign
government authority or SRO such information as
may be necessary to obtain from such authority or
organization additional information concerning the
individual's participation as a municipal securities
principal or representative who was associated with
a bank municipal securities dealer.
5. To disclose such information as may be necessary to respond to a request from a federal, state,
local or foreign government authority or SRO for
information needed in connection with the issuance
of a license, granting of a benefit, or similar action
affecting the applicant.
6. To disclose such information as may be necessary to respond to any Congressional inquiry made
at the request of the individual.