Form SBSE-A Form SBSE-A

Copy to Jack Habert, 12/28/201

Form SBSE-A

OMB Approval
OMB Number:
Expires:

3235-0696
January 31, 2019

Estimated average burden hours per
response:
per amendment:

34 hours
1 hour

Application for Registration
of Security-based Swap
Dealers and Major Securitybased Swap Participants that
are Registered or Registering
with the Commodity Futures
Trading Commission as a
Swap Dealer or Major Swap
Participant

SEC 2925 (1/16)

Persons who 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.

Copy to Jack Habert, 12/28/201

FORM SBSE-A INSTRUCTIONS

A.
1.

2.

3.

4.

4.

B.

GENERAL INSTRUCTIONS

FORM - Form SBSE-A is the Application for Registration as either a Security-based Swap Dealer or Major
Security-based Swap Participant (collectively, “SBS Entities”) by an entity that is not registered or registering with
the Commission as a broker-dealer but is registered or registering with the Commodity Futures Trading
Commission (“CFTC”) as a swap dealer or major swap participant. These SBS Entities must file this form and
a legible copy of the Form 7-R they file with the CFTC (or its designee) to register with the Securities and
Exchange Commission. An applicant must also file Schedules A, B, C, D and F, as appropriate. There is no
Schedule E. An entity that is registered or registering with the Commission as a broker-dealer and also is
registered or registering with the Commodity Futures Trading Commission (“CFTC”) as a swap dealer or major
swap participant should file Form SBSE-BD to register with the Commission as an SBS Entity.
ELECTRONIC FILING - This Form SBSE-A must be filed electronically with the Commission through the EDGAR
system, and must utilize the EDGAR Filer Manual (as defined in 17 CFR 232. 11) to file and amend Form SBSEA electronically to assure the timely acceptance and processing of those filings. Additional documents shall be
attached to this electronic application.
UPDATING - By law, the applicant must promptly update Form SBSE-A information by submitting amendments
whenever the information on file becomes inaccurate or incomplete for any reason [17 CFR 240.15Fb2-3]. In
addition, the applicant must update any incomplete or inaccurate information contained on Form SBSE-A prior to
filing a notice of withdrawal from registration on Form SBSE-W [17 CFR 15Fb3-2(a)].
CONTACT EMPLOYEE - The individual listed as the contact employee must be authorized to receive all

compliance information, communications, and mailings, and be responsible for disseminating it within the

applicant's organization.

FEDERAL INFORMATION LAW AND REQUIREMENTS - 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 15F, 17(a) and 23(a) of the Exchange Act authorize the SEC to collect the information on this form from
registrants. See 15 U.S.C. §§78o-10, 78q and 78w. Filing of this form is mandatory. The principal purpose of this
Form is to permit the Commission to determine whether the applicant meets the statutory requirement to engage
in the security-based swap business. The Commission maintains a file of the information on this form and will
make information collected via the form publicly available. Any member of the public may direct to the
Commission any comments concerning the accuracy of the burden estimate on this Form, and any suggestions
for reducing this burden. This collection of information has been reviewed by the Office of Management and
Budget in accordance with the 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.
FILING INSTRUCTIONS
1. F
ORMAT
a. Items 1-19 and the accompanying Schedules and DRP pages must be answered and all fields requiring a
response must be completed before the filing will be accepted.
b. Failure to follow instructions or properly complete the form may result in the application being delayed or
rejected.
c. Applicant must complete the execution screen certifying that Form SBSE-A and amendments thereto
have been executed properly and that the information contained therein is accurate and complete.
d. To amend information, the applicant must update the appropriate Form SBSE-A screens.
e. A paper copy, with original signatures, of the initial Form SBSE-A filing and amendments to Disclosure
Reporting Pages (DRPs) must be retained by the applicant and be made available for inspection upon a
regulatory request.
2. DISCLOSURE REPORTING PAGE (DRP) – Information concerning a principal that relates to the occurrence
of an event reportable in Schedule D must be provided on the appropriate DRP.

The mailing address for questions and correspondence is:
The Securities and Exchange Commission

Washington, DC 20549

Copy to Jack Habert, 12/28/2011

EXPLANATION OF TERMS

(The following terms are italicized throughout this form.)

1. GENERAL
Terms used in this Form SBSE-A that are defined in the form the CFTC requires that swap dealers and major swap
participants use to apply for registration with the CFTC shall have the same meaning as set forth in that form.
APPLICANT - The security-based swap dealer or major security-based swap participant applying on or amending this
form.
CONTROL - The power, directly or indirectly, to direct the management or policies of a company, whether through
ownership of securities, by contract, or otherwise. Any person that (i) is a director, general partner or officer exercising
executive responsibility (or having similar status or functions); (ii) directly or indirectly has the right to vote 25% or
more of a class of a voting security or has the power to sell or direct the sale of 25% or more of a class of voting
securities; or (iii) in the case of a partnership, has the right to receive upon dissolution, or has contributed, 25% or
more of the capital, is presumed to control that company.
JURISDICTION - A state, the District of Columbia, the Commonwealth of Puerto Rico, the U.S. Virgin Islands, or any
subdivision or regulatory body thereof.
SUCCESSOR –The term “successor” is defined to be an unregistered entity that assumes or acquires substantially all
of the assets and liabilities, and that continues the business of, a predecessor security-based swap dealer or major
security-based swap participants that ceases its security-based swap activities. [See Exchange Act Rule 15b2-5 (17
CFR 240.15Fb2-5)]
UNIQUE IDENTIFICATION CODE or UIC – For purposes of Form SBSE-A, the term “unique identification code” or
“UIC” means a unique identification code assigned to a person by an internationally recognized standards-setting
system that is recognized by the Commission [pursuant to Rule 903(a) of Regulation SBSR (17 CFR 242.903(a))].
3. FOR THE PURPOSE OF SCHEDULE D AND THE CORRESPONDING DISCLOSURE REPORTING PAGES
(DRPs)
FOREIGN FINANCIAL REGULATORY AUTHORITY - Includes (1) a foreign securities authority; (2) other
governmental body or foreign equivalent of a self-regulatory organization empowered by a foreign government to
administer or enforce its laws relating to the regulation of financial services industry-related activities; and (3) a foreign
membership organization, a function of which is to regulate the participation of its members in the activities listed
above.
FINANCIAL SERVICES INDUSTRY-RELATED – Pertaining to securities, commodities, banking, savings association
activities, credit union activities, 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, security-based swap dealer, major security-based swap participant,
savings association, credit union, insurance company, or insurance agency). (This definition is used solely for the
purpose of Form SBSE-A.)
INVOLVED - Doing an act or aiding, abetting, counseling, commanding, inducing, conspiring with or failing reasonably
to supervise another in doing an act.
ORDER - A written directive issued pursuant to statutory authority and procedures, including orders of denial,
suspension, or revocation; does not include special stipulations, undertakings or agreements relating to payments,
limitations on activity or other restrictions unless they are included in an order.
PROCEEDING - Includes a formal administrative or civil action initiated by a governmental agency, self-regulatory
organization or a foreign financial regulatory authority; a felony criminal indictment or information (or equivalent formal
charge); or a misdemeanor criminal information (or equivalent formal charge). Does not include other civil litigation,
investigations, or arrests or similar charges effected in the absence of a formal criminal indictment or information (or
equivalent formal charge).

Copy to Jack Habert, 12/28/201

Application for Registration as a Security-based
Swap Dealer and Major Security-based Swap
Participant that is Registered or Registering with
the CFTC as a Swap Dealer or Major Swap
Participant

FORM SBSE-A
Page 1
(Execution Page)

Official Use

Date:__________
Applicant NFA Number: ___________
Failure to keep this form current and to file accurate supplementary information on a timely basis, or the failure to keep
accurate books and records or otherwise to comply with the provisions of law applying to the conduct of business as an
WARNING:
SBS Entity, would violate the Federal securities laws and the laws of the jurisdictions and may result in disciplinary,
administrative, injunctive or criminal action.
INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACTS MAY CONSTITUTE FEDERAL CRIMINAL VIOLATIONS.
See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a)

[ ] APPLICATION
1.

[ ] AMENDMENT

Exact name, principal business address, mailing address, if different, and telephone number of the applicant:
A. Full name of the applicant:
B. IRS Empl. Ident. No.:
C. Applicant’s NFA ID #:

Applicant’s CIK # (if any):

D. Applicant’s Main Address: (Do not use a P.O. Box)
Number and Street 1:
City:

State:

E. Mailing Address, if different:
Number and Street 1:

Number and Street 2:
Country:

Zip/Postal Code:

Number and Street 2:

City:

State:

F. Business Telephone Number:
G Website/URL:
H. Contact Employee:
Name:
Telephone Number:

Applicant’s UIC # (if any):

Country:

Zip/Postal Code:

Title:
Email Address:

I. Chief Compliance Officer designated by the applicant in accordance with Exchange Act Section 15F(k):
Name:
Title:
Telephone Number:

Email Address:

EXECUTION:
The applicant consents that service of any civil action brought by or notice of any proceeding before the Securities and Exchange Commission in connection with the applicant’s security-based swap
activities, unless the applicant is a nonresident SBS Entity , may be given by registered or certified mail or confirmed telegram to the applicant’s contact employee at the main address, or mailing
address if different, given in Items 1E and 1F. If the applicant is a nonresident SBS Entity, it must complete Schedule F to designate a U.S. agent for service of process.
The undersigned certifies that he/she has executed this form on behalf of, and with the authority of, said applicant. The undersigned and applicant represent that the information and statements
contained herein, including schedules attached hereto, and other information filed herewith are current, true and complete. The undersigned and applicant further represent that to the extent any
information previously submitted is not amended such information is currently accurate and complete.

Date (MM/DD/YYYY)

Name of Applicant

By:
Signature

Name and Title of Person Signing on Applicant’s behalf
This page must always be completed in full.
DO NOT WRITE BELOW THIS LINE – FOR OFFICIAL USE ONLY

Official
Use
Only

Copy to Jack Habert, 12/28/201

FORM SBSE-A
Page 2
2.

3.

Date:__________

Official
Use
Only

Official Use

Applicant Name: _____________________________________
Applicant NFA No.: __________

A.

The applicant is registering as a security-based swap dealer:

[ ] Yes

[ ] No

B.

The applicant is registering as a major security-based swap participant:
[ ] Yes
[ ] No
Because it: (check all that apply)
[ ] maintains a substantial security-based swap position
[ ] has substantial counterparty exposure
[ ] is highly leveraged relative to its capital position

A.

Is the applicant a foreign security-based swap dealer that intends to:
 work with the Commission and its primary regulator to have the Commission determine whether the
requirements of its primary regulator’s regulatory system are comparable to the Commission’s [ ] Yes [ ] No
 avail itself of a previously granted substituted compliance determination
[ ] Yes [ ] No
with respect to the requirements of Section 15F of the Exchange Act of 1934 and the rules and regulations
thereunder?

B.

If “yes” to either of the questions in Item 3.A. above, identify the foreign financial regulatory authority that serves
as the applicant’s primary regulator and for which the Commission has made, or may make, a substituted
compliance determination:
____________________________________________________________________________________________
__________________________________________________________________________________.

C.

If the applicant is relying on a previously granted substituted compliance determination, please describe how the
applicant satisfies any conditions the Commission may have placed on such substituted compliance
determination:
__________________________________________________________________________________________
____________________________________________________________________________________.

4.

Does the applicant intend to compute capital or margin, or price customer or proprietary positions, using mathematical
models?
[ ] Yes
[ ] No

5.

A.

The applicant is currently registered with the Commodity Futures Trading Commission as a:
[ ] Swap Dealer
[ ] Major Swap Participant

B.

The applicant is registering with the Commodity Futures Trading Commission as a:
[ ] Swap Dealer
[ ] Major Swap Participant

6.

Is the applicant a U.S. branch of a non-resident entity?
[ ] Yes
[ ] No
If “yes,” identify the non-resident entity and its location:
________________________________________________________________________________________________.

7.

Briefly describe the applicant’s business: ______________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
YES NO
Is the applicant subject to regulation by a prudential regulator, as defined in Section 1a(39) of the
Commodity Exchange Act. If “yes,” identify the prudential regulator: ____________________________. [ ] [ ]

8.
9.

Is the applicant registered with the Commission as an investment adviser?
Applicant’s IARD #: _____________________________________

[ ]

[ ]

10. A.

Is the applicant registered with the Commodity Futures Trading Commission in any capacity other than
as a swap dealer or major swap participant?

[ ]

[ ]

B.

If “yes,” as a:

[ ] Futures Commission Merchant
[ ] Commodity Pool Operator

[ ] Introducing Broker
[ ] Other: ________________________

11.

Does applicant engage in any other non-securities, financial services industry-related business?
If “yes,” describe each other business briefly on Schedule B, Section I.

[ ]

[ ]

12.

Does the applicant hold or maintain any funds or securities to collateralize counterparty transactions?

[ ]

[ ]

Copy to Jack Habert, 12/28/2011

FORM SBSE-A
Page 3
13.
A.

Applicant Name: _____________________________________
Date:__________

Official
Use
Only

Official Use

Applicant NFA No.: __________

Does the applicant have any arrangement:
With any other person, firm, or organization under which any books or records of the applicant are kept,
maintained, or audited by such other person, firm or organization?

YES NO
[ ]

[ ]

Under which such other person, firm or organization executes, trades, custodies, clears or settles on
behalf of the applicant (including any SRO in which the applicant is a member)?
If “yes” to any part of Item 11, complete appropriate items on Schedule B, Section II.

[ ]

[ ]

14.

Does any person directly or indirectly control the management or policies of the applicant through
agreement or otherwise?
If “yes,” complete appropriate item on Schedule B, Section II.

[ ]

[ ]

15.

Does any person directly or indirectly finance (wholly or partially) the business of the applicant?
Do not answer “Yes” to Item 15 if the person finances the business of the applicant through: 1) a public
offering of securities made pursuant to the Securities Act of 1933; or 2) credit extended in the ordinary
course of business by suppliers, banks, and others.
If “yes,” complete appropriate item on Schedule B, Section II.

[ ]

[ ]

16.

Is the applicant at the time of this filing succeeding to the business of a currently registered SBS Entity?
If “yes,” complete appropriate items on Schedule B, Section III.

[ ]

[ ]

17.

Is the applicant registered with a foreign financial regulatory authority?
If “yes,” list all such registrations on Schedule F, Page 1, Section II.

[ ]

[ ]

18.

The applicant has ______ principals who are individuals.
Please list all principals who are individuals on Schedule A.

19.

Does any principal not identified in Item 18 and Schedule A effect, or is any principal not identified in Item 18 and
Schedule A involved in effecting security-based swaps on behalf of the applicant, or will such principals effect or be
involved in effecting such business on the applicant’s behalf?
If “yes,” complete appropriate item on Schedule B, Section IV.

B.

Copy to Jack Habert, 12/28/201

Schedule A of FORM
SBSE-A

Official Use
Applicant Name: ___________________________________

PRINCIPALS THAT ARE
Date:__________
INDIVIDUALS
(Answer for Form SBSE-A Item 18)

Applicant NFA No.: __________

Use Schedule A to identify all principals of the applicant who are individuals.
Complete the “Title or Status” column by entering board/management titles; status as partner, trustee, sole proprietor, or
shareholder; and for shareholders, the class of securities owned (if more than one is issued).
Ownership Codes are:
NA less than 5%
A 5% but less than 10%
FULL LEGAL NAME
(Individuals: Last Name, First Name, Middle
Name)

1.

B C Title or Status

10% but less than 25%
25% but less than 50%

D E -

50% but less than 75%
75% or more

Date Title or Date Individual Does person If yes,
have an
include
Status Acquired began working
ownership ownership
for applicant
interest in
code
MM
YYYY
MM
YYYY the applicant

NFA Identification No., CRD No.
and/or IARD No.

Official
Use
Only

Y/N
For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior
position - employer, job title, and dates of service):

2.

Y/N
For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior
position - employer, job title, and dates of service):

3.

Y/N
For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior
position - employer, job title, and dates of service):

4.

Y/N
For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior
position - employer, job title, and dates of service):

5.

Y/N
For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior
position - employer, job title, and dates of service):

6.

Y/N
For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior
position - employer, job title, and dates of service):

7.

Y/N
For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior
position - employer, job title, and dates of service):

8.

Y/N
For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior
position - employer, job title, and dates of service):

9.

Y/N
For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior
position - employer, job title, and dates of service):

10.

Y/N
For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior
position - employer, job title, and dates of service):

Copy to Jack Habert, 12/28/201

Schedule B of FORM
SBSE-A
Page 1

Applicant Name: _____________________________________
Date:__________

Official Use

Applicant NFA No.: __________

Use this Schedule B to report details for items listed below. Report only new information or changes/updates to
previously submitted details. Do not repeat previously submitted information.
This is an [ ] INITIAL
[ ] AMENDED detail filing for the Form SBSE-A items checked below:

Section I

Other Business

Item 11: Does applicant engage in any other non-securities, financial services industry-related business?
UIC (if any), or other Unique Identification Number(s):

Assigning Regulator(s)/Entity(s):

Briefly describe any other financial services industry-related, non-securities business in which the applicant is engaged:

Section II

Record Maintenance Arrangements / Business Arrangements / Control Persons / Financings

(Check one)
[ ] Item 13A
[ ] Item 13B
[ ] Item 14
[ ] Item 15
Applicant must complete a separate Schedule B Page 1 for each affirmative response in this section including any
multiple responses to any item. Complete the “Effective Date” box with the Month, Day and Year that the arrangement
or agreement became effective. When reporting a change or termination of an arrangement, enter the effective date
of the change.
Firm or Organization Name

SEC File, CRD, NFA, IARD, UIC, and/or CIK Number (if
any)

Business Address (Street, City, State/Country, Zip + 4 Postal Code)

Effective Date
MM DD YYYY

Individual Name

CRD, NFA, and/or IARD Number (if any)

Business Address (if applicable) (Street, City, State/Country, Zip + 4 Postal Code)

Effective Date
MM DD YYYY

/

/

/

/

Termination Date
MM DD YYYY

/

/

Termination Date
MM DD YYYY

/

/

Briefly describe the nature of the arrangement with respect to books or records (ITEM 13A); the nature of the execution, trading, custody, clearing or
settlement arrangement (ITEM 13B); the nature of the control or agreement (ITEM 14); or the method and amount of financing (ITEM 15). Use reverse
side of this sheet for additional comments if necessary.
For ITEM 14 ONLY - If the control person is an individual not presently registered through CRD or IARD, describe prior investment-related experience (e.g., for each prior position
- employer, job title, and dates of service).

Section III

Successions

Item 16: Is the applicant at the time of this filing succeeding to the business of a currently registered SBS Entity?
Date of Succession

MM DD YYYY

/

Name of Predecessor

/

SEC File, CRD, NFA, IARD, UIC, and/or CIK Number (if any)

IRS Employer Number (if any)

Briefly describe details of the succession including any assets or liabilities not assumed by the successor. Use reverse side of this sheet for additional
comments if necessary.

Section IV

Principals Effecting or Involved in Effecting SBS Business

Item 19: Does any principal not identified in Item 18 and Schedule A effect, or is any principal not identified in Item 15
and Schedule A involved in effecting security-based swaps on behalf of the applicant, or will such principals effect or
be involved in effecting such business on the applicant’s behalf?
For each Principal identified in Section IV, complete Schedule D of the Form SBSE-A and the relevant DRP pages.
1.

Name of Principal

Type of Entity (Corp, Partnership,
LLC, etc.)

SEC File No., CRD, NFA, IARD, CIK Number, UIC
(if any), and/or Tax Identification Number

Business Address (Street, City, State/Country, Zip + 4/Postal Code)

This entity [ ] effects

[ ] is involved in effecting security based swaps on behalf of the applicant. (check only

one)

Briefly describe the details of the principal’s activities relating to its effecting or involvement in effecting security-based swap transactions on behalf of the
applicant:

Official
Use
Only

Copy to Jack Habert, 12/28/201

Schedule B of FORM
SBSE-A
Page 2

Section IV, Continued

Applicant Name: _____________________________________
Date:__________

Official Use

Applicant NFA No.: __________

Principals Effecting or Involved in Effecting SBS Business

For each Principal identified in Section IV, complete Schedule D of the Form SBSE-A and the relevant DRP pages.
2.

Name of Principal

Type of Entity (Corp, Partnership,
LLC, etc.)

SEC File No., CRD, NFA, IARD, CIK Number, UIC
(if any), and/or Tax Identification Number

Business Address (Street, City, State/Country, Zip + 4/Postal Code)

This entity [ ] effects

[ ] is involved in effecting security based swaps on behalf of the applicant. (check only one)

Briefly describe the details of the principal’s activities relating to its effecting or involvement in effecting security-based
swap transactions on behalf of the applicant:

3.

Name of Principal

Type of Entity (Corp, Partnership,
LLC, etc.)

SEC File No., CRD, NFA, IARD, CIK Number, UIC
(if any), and/or Tax Identification Number

Business Address (Street, City, State/Country, Zip + 4/Postal Code)

This entity [ ] effects

[ ] is involved in effecting security based swaps on behalf of the applicant. (check only one)

Briefly describe the details of the principal’s activities relating to its effecting or involvement in effecting security-based
swap transactions on behalf of the applicant:

4.

Name of Principal

Type of Entity (Corp, Partnership,
LLC, etc.)

SEC File No., CRD, NFA, IARD, CIK Number, UIC
(if any), and/or Tax Identification Number

Business Address (Street, City, State/Country, Zip + 4/Postal Code)

This entity [ ] effects

[ ] is involved in effecting security based swaps on behalf of the applicant. (check only one)

Briefly describe the details of the principal’s activities relating to its effecting or involvement in effecting security-based
swap transactions on behalf of the applicant:

5.

Name of Principal

Type of Entity (Corp, Partnership,
LLC, etc.)

SEC File No., CRD, NFA, IARD, CIK Number, UIC
(if any), and/or Tax Identification Number

Business Address (Street, City, State/Country, Zip + 4/Postal Code)

This entity [ ] effects

[ ] is involved in effecting security based swaps on behalf of the applicant. (check only one)

Briefly describe the details of the principal’s activities relating to its effecting or involvement in effecting security-based
swap transactions on behalf of the applicant:

6.

Name of Principal

Type of Entity (Corp, Partnership,
LLC, etc.)

SEC File No., CRD, NFA, IARD, CIK Number, UIC
(if any), and/or Tax Identification Number

Business Address (Street, City, State/Country, Zip + 4/Postal Code)

This entity [ ] effects

[ ] is involved in effecting security based swaps on behalf of the applicant. (check only one)

Briefly describe the details of the principal’s activities relating to its effecting or involvement in effecting security-based
swap transactions on behalf of the applicant:

Official
Use
Only

Copy to Jack Habert, 12/28/2011

Schedule C of FORM
SBSE-A

Applicant Name: _________________________________

LIST OF 15Fb6-1 ENTITIES

Date:__________

Official Use

SEC Filer No: __________

Each applicant shall use Schedule C to identify each person associated with it, as of the date it files an
application to register with the Commission, that is not a natural person and that is subject to statutory
disqualification (as described in Exchange Act Sections 3(a)(39)(A) through (F)) that the security-based swap
dealer or security-based swap participant permits to effect or be involved in effecting security-based swaps on
its behalf pursuant to Rule 15Fb6-1.

NAME
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Official Use
Only

Copy to Jack Habert, 12/28/201

Schedule D of
FORM SBSE-A
Page 1

Applicant Name: ___________________________________

Official
Use
Only

Official Use

Principal Name: ____________________________________
Date:__________

Applicant NFA No.: __________

Use the appropriate DRP for providing details to “yes” answers to the questions in Schedule D. Refer to the
Explanation of Terms section of Form SBSE-A Instructions for explanations of italicized terms.

CRIMINAL DISCLOSURE

A. In the past ten years has the principal:
(1) Been convicted of or pled guilty or nolo contendere (“no contest”) in a domestic, foreign or military
court to any felony?

YES NO
[ ] [ ]
[ ]

[ ]

(1) Been convicted of or pled guilty or or nolo contendere (“no contest”) in a domestic, foreign or military
court to a misdemeanor involving: financial services industry-related business, or any fraud, false
statements or omissions, wrongful taking of property, bribery, perjury, forgery, counterfeiting,
extortion, or a conspiracy to commit any of these offenses?

[ ]

[ ]

(2) Been charged with a misdemeanor specified in B(1)?

[ ]

[ ]

(1) Found the principal to have made a false statement or omission?

[ ]

[ ]

(2) Found the principal to have been involved in a violation of its regulations or statutes?

[ ]

[ ]

(3) Found the principal to have been a cause of a financial services industry-related business having its
authorization to do business denied, revoked, or restricted?

[ ]

[ ]

(4) Entered an order against the principal in connection with financial services industry-related activity?

[ ]

[ ]

(5) Imposed a civil money penalty on the principal, or ordered the principal to cease and desist from any
activity?

[ ]

[ ]

(1) Ever found the principal to have made a false statement or omission or been dishonest, unfair, or
unethical?

[ ]

[ ]

(2) Ever found the principal to have been involved in a violation of financial services industry-related
regulations or statutes?

[ ]

[ ]

(3) Ever found the principal to have been a cause of a financial services industry-related business
having its authorization to do business denied, suspended, revoked or restricted?

[ ]

[ ]

(4) In the past ten years, entered an order against the principal in connection with a financial services
industry-related activity?

[ ]

[ ]

(5) Ever denied, suspended, or revoked the principal’s registration or license or otherwise, by order,
prevented it from associating with a financial services industry-related business or restricted its
activities?

[ ]

[ ]

[ ]

[ ]

[ ]
(2) found the principal to have been involved in a violation of its rules (other than a violation designated
as a “minor rule violation” under a plan approved by the U.S. Securities and exchange Commission)?

[ ]

(3) found the principal to have been the cause of a financial services industry-related business having its
authorization to do business denied, suspended, revoked or restricted?

[ ]

[ ]

(4) Disciplined the principal by expelling or suspending it from membership, barring or suspending its
association with other members, or otherwise restricting its activities?

[ ]

[ ]

F. Has the principal’s authorization to act as an attorney, accountant, or federal contractor ever been
revoked or suspended?

[ ]

[ ]

G. Is the principal now the subject of any regulatory proceeding that could result in a “yes” answer to any
part of C, D, or E?

[ ]

[ ]

(2) Been charged with a felony
B. In the past ten years has the principal:

REGULATORY ACTION
DISCLOSURE

C. Has the U.S. Securities and Exchange Commission or the Commodity Futures Trading Commission ever:

REGULATORY ACTION DISCLOSURE

D. Has any other federal regulatory agency, state regulatory agency, or foreign financial regulatory authority:

E. Has any self-regulatory organization or commodities exchange ever:
(1) found the principal to have made a false statement or omission?

Copy to Jack Habert, 12/28/201

Schedule D of
FORM SBSE-A
Page 2
CIVIL JUDICIAL DISCLOSURE

H.

Applicant Name: ___________________________________

Official Use

Principal Name: ____________________________________
Date:__________

Applicant NFA No.: __________

(1) Has any domestic or foreign civil judicial court:
(a) In the past ten years, enjoined the principal in connection with any financial services
industry-related activity?

YES NO
[ ] [ ]
[
] [ ]
(b) Ever found that the principal was involved in a violation of financial services industry-related
statutes or regulations?
[ ]

[ ]

[ ]

[ ]

(1) Has been the subject of a bankruptcy petition?

[ ]

[ ]

(2) Has had a trustee appointed or a direct payment procedure initiated under the Securities
Investor Protection Act?

[ ]

[ ]

(c) Ever dismissed, pursuant to a settlement agreement, a financial services industry-related
civil judicial action brought against the principal by a state or foreign financial regulatory
authority?
(2) Is the principal now the subject of any civil judicial proceeding that could result in a “yes” answer
to any part of H(1)?

FINANCIAL
DISCLOSURE

I.

In the past ten years has the principal ever been a securities firm or a principal of a securities firm
that:

Official
Use
Only

Copy to Jack Habert, 12/28/201

Schedule F of FORM
SBSE-A
Section I

Official Use

Applicant Name: _________________________________
Date:__________

Applicant NFA No.: __________

Service of Process and Certification Regarding Access to Records

Each nonresident security-based swap dealer and non-resident security-based swap participant shall use Schedule F to identify
its United States agent for service of process and the certify that it can as a matter of law, and will (1) provide the Commission with prompt access to its books and records, and
(2) submit to onsite inspection and examination by the Commission.
1. Service of Process:
A.

Name of United States person applicant designates and appoints as agent for service of process

B.

Address of United States person applicant designates and appoints as agent for service of process

The above identified agent for service of process may be served any process, pleadings, subpoenas, or other papers in
(a) any investigation or administrative proceeding conducted by the Commission that relates to the applicant or about which the
applicant may have information; and
(b) any civil or criminal suit or action or proceeding brought against the applicant or to which the applicant has been joined as
defendant or respondent, in any appropriate court in any place subject to the jurisdiction of any state or of the United States or of
any of its territories or possessions or of the District of Columbia, to enforce the Exchange Act. The applicant has stipulated and
agreed that any such suit, action or administrative proceeding may be commenced by the service of process upon, and that
service of an administrative subpoena shall be effected by service upon the above-named Agent for Service of Process, and that
service as aforesaid shall be taken and held in all courts and administrative tribunals to be valid and binding as if personal
service thereof had been made.

2. Certification regarding access to records:
Applicant can as a matter of law, and will;
(1) provide the Commission with prompt access to its books and records, and
(2) submit to onsite inspection and examination by the Commission.
Applicant must attach to this Form SBSE a copy of the opinion of counsel it is required to obtain in accordance with
paragraph (c)(2) or (c)(3) of Exchange Act Rule 15Fb2-4, as appropriate [paragraphs (c)(2) or (c)(3) of 17 CFR
240.15Fb2-4].
Signature:
Name and Title:
Date:

Section II

Registration with Foreign Financial Regulatory Authorities

Complete this Section for Registration with Foreign Financial Regulatory Authorities relating to ITEM 17. Each securitybased swap dealer and major security-based swap participant that is registered with a foreign financial regulatory authority must list on Section II
of this Schedule F, for each foreign financial regulatory authority with which it is registered, the following information:

1 ________________________________________________________
. English Name of Foreign Financial Regulatory Authority

___________________

__________________

Foreign Registration No. (if any)

English Name of Country:

2 ________________________________________________________
. English Name of Foreign Financial Regulatory Authority

___________________

__________________

Foreign Registration No. (if any)

English Name of Country:

3 ________________________________________________________
. English Name of Foreign Financial Regulatory Authority

___________________

__________________

Foreign Registration No. (if any)

English Name of Country:

If applicant has more than 3 Foreign Financial Regulatory Authorities to report, complete additional Schedule F Page 1s.

Copy to Jack Habert, 12/28/201

CRIMINAL DISCLOSURE REPORTING PAGE (SBSE-A)

GENERAL INSTRUCTIONS
This Disclosure Reporting Page [DRP (SBSE)] is an [ ] INITIAL OR [ ] AMENDED response to report details for
affirmative responses to Items A and B of Schedule D of Form SBSE-A;
Check [√] item(s) being responded to:
A. In the past ten years has the principal:
[ ] (1) Been convicted of or pled guilty or nolo contendere (“no contest”) in a domestic, foreign or military
court to any felony?
[ ] (2) Been charged with a felony?
B. In the past ten years has the principal:
[ ] (1) Been convicted of or pled guilty or or nolo contendere (“no contest”) in a domestic, foreign or military
court to a misdemeanor involving: investments or an investment-related business, or any fraud, false
statements or omissions, wrongful taking of property, bribery, perjury, forgery, counterfeiting, extortion, or a
conspiracy to commit any of these offenses?
[ ] (2) Been charged with a misdemeanor specified in B(1)?
Use a separate DRP for each event or proceeding. An event or proceeding may be reported for more than one person or
entity using one DRP. File with a completed Execution Page.
Multiple counts of the same charge arising out of the same event(s) should be reported on the same DRP. Unrelated
criminal actions, including separate cases arising out of the same event, must be reported on separate DRPs. Use this
DRP to report all charges arising out of the same event. One event may result in more than one affirmative answer to the
above items.
If a principal is an organization registered through the CRD, such principal need only complete Part I of the applicant’s
appropriate DRP (SBSE-A). Details of the event must be submitted on the principal’s appropriate DRP (BD) or DRP (U-4).
If a principal is an individual or organization not registered through the CRD, provide complete answers to all the items on
the applicant’s appropriate DRP (SBSE-A). The completion of this DRP does not relieve the principal of its obligation to
update its CRD records.
Applicants must attach a copy of each applicable court document (i.e., criminal complaint, information or indictment as well
as judgment of conviction or sentencing documents) if not previously submitted through CRD (as they could be in the case
of a control affiliate registered through CRD). Documents will not be accepted as disclosure in lieu of answering the
questions on this DRP.

PART I
A.

If the principal is registered with the CRD, provide the CRD number. If not, indicate “non-registered” by checking the
appropriate checkbox.
Name of Principal
CRD NUMBER

Registered:

[ ] Yes

[ ] No

[ ] This DRP should be removed from the SBS Entity’s record because the principal is no longer associated with
the SBS Entity.
B.

If the principal is registered through the CRD, has the principal submitted a DRP (with Form U-4) or DRP (BD) to the
CRD System for the event?
If the answer is “Yes,” no other information on this DRP must be provided: If “No,” complete Part II.

[ ] Yes
[ ] No

Note: The completion of this Form does not relieve the principal of its obligation to update its CRD records.

Copy to Jack Habert, 12/28/201

CRIMINAL DISCLOSURE REPORTING PAGE (SBSE-A)
(continuation)

PART II
1.

If charge(s) were brought against an organization over which the principal exercise(d) control: Enter organization
name, whether or not the organization was an investment-related business and the principal’s position, title or
relationship.
___________________________________________________________________________________________

2.

Formal Charge(s) were brought in: (include name of Federal, Military, State or Foreign Court, Location of Court – City
or County and State or Country, Docket/Case number).
____________________________________________________________________________________________

3.

Event Disclosure Detail (Use this for both organizational and individual charges.)
A. Date First Charged (MM/DD/YYYY):

[ ] Exact

[ ] Explanation

If not exact, provide explanation: _________________________________________________________________
B.

Disclosure Detail (include Charge(s)/Charge Description(s), and for each charge provide: 1. number of
Event
counts, 2. felony or misdemeanor, 3. plea for each charge, and 4. product type if charge is investment-related):

___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
C. Current status of the Event?
D.

[ ] Pending

Event Status Date (complete unless status is
Pending) (MM/DD/YYYY):

[ ] On Appeal

[ ] Final
[ ] Exact

[ ] Explanation

If not exact, provide explanation: _________________________________________________________________
4.

Disposition Disclosure Detail: Include for each charge, A. Disposition Type [e.g., convicted, acquitted, dismissed,
pretrial.], B. Date, C. Sentence/Penalty, D. Duration [if sentence-suspension, probation, etc.], E. Start Date of Penalty,
F. Penalty/Fine Amount and G. Date Paid.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

5.

Provide a brief summary of the circumstances leading to the charge(s) as well as the disposition. Include the relevant
dates when the conduct which was the subject of the charge(s) occurred. (The information must fit within the space
provided.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Copy to Jack Habert, 12/28/201

REGULATORY ACTION DISCLOSURE REPORTING PAGE (SBSE-A)

GENERAL INSTRUCTIONS
This Disclosure Reporting Page [DRP (SBSE)] is an [ ] INITIAL OR [ ] AMENDED response to report details for affirmative
responses to Items C, D, E, F, or G of Schedule D of Form SBSE-A;
Check [√] item(s) being responded to:
C. Has the U.S. Securities and Exchange Commission or the Commodity Futures Trading Commission ever:
[ ] (1) Found the principal to have made a false statement or omission?
[ ] (2) Found the principal to have been involved in a violation of its regulations or statutes?
[ ] (3) the principal to have been a cause of an investment-related business having its authorization to do business denied, revoked, or restricted?
[ ] (4) Entered an order against the principal in connection with investment-related activity?
[ ] (5) Imposed a civil money penalty on the principal, or ordered the principal to cease and desist from any activity?
D. Has any other federal regulatory agency, state regulatory agency, or foreign financial regulatory authority:
[ ] (1) Ever found the principal to have made a false statement or omission or been dishonest, unfair, or unethical?
[ ] (2) Ever found the principal to have been involved in a violation of investment-related regulations or statutes?
[ ] (3) Ever found the principal to have been a cause of an investment-related business having its authorization to do business denied, suspended, revoked or
restricted?
[ ] (4) In the past ten years, entered an order against the principal in connection with an investment-related activity?
[ ] (5) Ever denied, suspended, or revoked the principal’s registration or license or otherwise, by order, prevented it from associating with an investment-related
business or restricted its activities?
E. Has any self-regulatory organization or commodities exchange ever:
[ ] (1) found the principal to have made a false statement or omission?
[ ] (2) found the principal to have been involved in a violation of its rules (other than a violation designated as a “minor rule violation” under a plan approved by the
U.S. Securities and exchange Commission)?
[ ] (3) found the principal to have been the cause of an investment-related business having its authorization to do business denied, suspended, revoked or restricted?
[ ] (4) Disciplined the principal by expelling or suspending it from membership, barring or suspending its association with other members, or otherwise restricting its
activities?
F. [ ] Has the principal’s authorization to act as an attorney, accountant, or federal contractor ever been revoked or suspended?
G. [ ] Is the principal now the subject of any regulatory proceeding that could result in a “yes” answer to any part of C, D, or E?

Use a separate DRP for each event or proceeding. An event or proceeding may be reported for more than one person or entity using one
DRP. File with a completed Execution Page.
One event may result in more than one affirmative answer to Items C, D, E, F or G. Use only one DRP to report details related to the same
event. If an event gives rise to actions by more than one regulator, provide details for each action on a separate DRP.
It is not a requirement that documents be provided for each event or proceeding. Should they be provided, they will not be accepted as
disclosure in lieu of answering the questions on this DRP.
If the principal is an organization registered through the CRD, such principal need only complete Part I of the applicant’s appropriate DRP
(SBSE). Details of the event must be submitted on the principal’s appropriate DRP (BD) or DRP (U-4). If a principal is an organization not
registered through the CRD, provide complete answers to all the items on the applicant’s appropriate DRP (SBSE). The completion of this
DRP does not relieve the prinicipal of its obligation to update its CRD records.

PART I
A.

If the principal is registered with the CRD, provide the CRD number. If not, indicate “non-registered” by checking the
appropriate checkbox.
Name of Principal
Registered:

[ ] Yes

Principal’s CRD Number
[ ] No

[ ] This DRP should be removed from the SBS Entity record because the control affiliate(s) are no longer associated
with the SBS Entity.
B.

If the principal is registered through the CRD, has the principal submitted a DRP (with Form U-4) or DRP (BD) to the

CRD System for the event?

If the answer is “Yes,” no other information on this DRP must be provided: If “No,” complete Part II.

[ ] Yes

[ ] No

Note: The completion of this Form does not relieve the principal of its obligation to update its CRD records.

Copy to Jack Habert, 12/28/201

REGULATORY ACTION DISCLOSURE REPORTING PAGE (SBSE-A)
(continuation)

PART II
1.

Regulatory Action initiated by:
[ ] SEC
[ ] Other Federal
[ ] State
[ ] SRO
[ ] Foreign
(Full name of regulator, foreign financial regulatory authority, federal, state or SRO)

2.

Principal Sanction: (check appropriate item)
[
[
[
[
[

]
]
]
]
]

Civil and Administrative Penalty(ies)/Fine(s)
Bar
Cease and Desist
Censure
Denial

[
[
[
[
[

]
]
]
]
]

Disgorgement
Expulsion
Injunction
Prohibition
Reprimand

[
[
[
[
[

]
]
]
]
]

Restitution
Revocation
Suspension
Undertaking
Other ____________________

Other Sanctions:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
3.

3.

Date Initiated (MM/DD/YYYY)

[ ] Exact

[ ] Explanation

If not exact, provide explanation: __________________________________________________________________
4.

Docket/Case Number:

5.

Principal Employing Firm when activity occurred which led to the regulatory action (if applicable):

6.

Principal Product Type: (check appropriate item)
[ ] Annuity(ies) - Fixed
[ ] Annuity(ies) - Variable
[ ] Banking Products (other
than CD(s))
[ ] CD(s)
[ ] Commodity Option(s)
[ ] Debt – Asset Backed
[ ] Debt - Corporate
[ ] Debt - Government

[ ] Debt - Municipal
[
[
[
[
[
[
[
[

]
]
]
]
]
]
]
]

Derivative(s)
Direct Investment(s) – DPP & LP Interest(s)
Equity - OTC
Equity Listed (Common & Preferred Stock)
Futures - Commodity
Futures - Financial
Index Option(s)
Insurance

[
[
[
[
[
[
[
[

]
]
]
]
]
]
]
]

Investment Contract(s)
Money Market Fund(s)
Mutual Fund(s)
No Product
Options
Penny Stock(s)
Unit Investment Trust(s)
Other _________________

Other Product Type:

7.

Describe the allegations related to this regulatory action. (The information must fit within the space provided.):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

8.

Current Status?

[ ] Pending

[ ] On Appeal

[ ] Final

9.

If on appeal, regulatory action appealed to: (SEC, SRO, Federal or State Court) and Date Appeal Filed:

Copy to Jack Habert, 12/28/201

REGULATORY ACTION DISCLOSURE REPORTING PAGE (SBSE-A)
(continuation)
If Final or On Appeal, complete all items below. For Pending Actions, complete Item 13 only.
10.

How was matter resolved: (check appropriate item)
[ ] Acceptance, Waiver & Consent (AWC)
[ ] Decision & Order of Offer of Settlement
[ ] Decision

[ ] Consent
[ ] Dismissed
[ ] Order

[ ] Settled
[ ] Stipulation and Consent
[ ] Vacated

3.

11.

Resolution Date (MM/DD/YYYY)

[ ] Exact

[ ] Explanation

If not exact, provide explanation:
12.

A.

Were any of the following Sanctions Ordered? (Check all appropriate items):
[ ] Monetary/Fine
Amount $________

[ ] Revocation/Expulsion/Denial
[ ] Censure

[ ] Disgorgement/Restitution

[ ] Cease and Desist/Injunction

[ ] Bar

[ ] Suspension

B. Other Sanctions Ordered:

C. Sanction Detail: If suspended, enjoined or barred, provide duration including start date and capacities affected
(General Securities Principal, Financial Operations Principal, etc.). If requalification, by exam/retraining was a
condition of the sanction, provide length of time given to re-qualify/retrain, type of exam required and whether
condition has been satisfied. If disposition resulted in a fine, penalty, restitution, disgorgement or monetary
compensation, provide total amount, portion levied against principal, date paid and if any portion of penalty was
waived.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
13.

Provide a brief summary of details related to the action status and (or) disposition and include relevant terms,
conditions and dates. (The information must fit within the space provided.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Copy to Jack Habert, 12/28/201

CIVIL JUDICIAL ACTION DISCLOSURE REPORTING PAGE (SBSE-A)

GENERAL INSTRUCTIONS
This Disclosure Reporting Page [DRP (SBSE-A)] is an [ ] INITIAL OR [ ] AMENDED response to report details for
affirmative responses to Item H of Schedule D of Form SBSE-A;
Check [√] item(s) being responded to:
H(1) Has any domestic or foreign civil judicial court:
[ ] (a) in the past ten years, enjoined the principal in connection with any investment-related activity?
[ ] (b) ever found that the principal was involved in a violation of investment-related statutes or
regulations?
[ ] (c) ever dismissed, pursuant to a settlement agreement, an investment-related civil judicial action
brought against the principal by a state or foreign financial regulatory authority?
H(2) [ ] Is the principal now the subject of any civil judicial proceeding that could result in a “yes” answer to any
part of H?
Use a separate DRP for each event or proceeding. An event or proceeding may be reported for more than one person or entity using one
DRP. File with a completed Execution Page.
One event may result in more than one affirmative answer to Item H. Use only one DRP to report details related to the same event.
Unrelated civil judicial actions must be reported on separate DRPs.
It is not a requirement that documents be provided for each event or proceeding. Should they be provided, they will not be accepted as
disclosure in lieu of answering the questions on this DRP.
If a principal is an individual or organization registered through the CRD, such principal need only complete Part I of the applicant’s
appropriate DRP (SBSE-A). Details of the event must be submitted on the principal’s appropriate DRP (BD) or DRP (U-4). If a principal is an
organization not registered through the CRD, provide complete answers to all the items on the applicant’s appropriate DRP (SBSE-A). The
completion of this DRP does not relieve the principal of its obligation to update its CRD records.

PART I
A.

If the principal is registered with the CRD, provide the CRD number. If not, indicate “non-registered” by checking the
appropriate checkbox.
Name of Principal
CRD NUMBER

Registered:

[ ] Yes

[ ] No

[ ] This DRP should be removed from the SBS Entity’s record because the principal is no longer associated with the
SBS Entity.
B.

If the principal is registered through the CRD, has the principal submitted a DRP (with Form U-4) or DRP (BD) to the
CRD System for the event?
If the answer is “Yes,” no other information on this DRP must be provided: If “No,” complete Part II.

[ ] Yes
[ ] No

Note: The completion of this Form does not relieve the principal of its obligation to update its CRD records.

Copy to Jack Habert, 12/28/201

CIVIL JUDICIAL ACTION DISCLOSURE REPORTING PAGE (SBSE-A)
(continuation)

PART II
1.

Court Action initiated by: (Name of regulator, foreign financial regulatory authority, SRO, commodities exchange,
agency, firm, private plaintiff, etc.)

2.

Principal Relief Sought: (check appropriate item)
[ ] Cease and Desist
[ ] Civil Penalty(ies)/Fine(s)

[ ] Disgorgement
[ ] Injunction

[ ] Money Damages (Private/Civil Complaint)
[ ] Restitution

[ ] Restraining Order
[ ] Other __________

Other Relief Sought:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
3.

3.

Filing Date of Court Action (MM/DD/YYYY)

[ ] Exact

[ ] Explanation

If not exact, provide explanation: __________________________________________________________________
4.

Principal Product Type: (check appropriate item)
[ ] Annuity(ies) - Fixed
[ ] Annuity(ies) - Variable
[ ] Banking Products (other
than CD(s))
[ ] CD(s)
[ ] Commodity Option(s)
[ ] Debt – Asset Backed
[ ] Debt - Corporate
[ ] Debt - Government

[
[
[
[
[
[
[
[
[

]
]
]
]
]
]
]
]
]

Debt - Municipal
Derivative(s)
Direct Investment(s) – DPP & LP Interest(s)
Equity - OTC
Equity Listed (Common & Preferred Stock)
Futures - Commodity
Futures - Financial
Index Option(s)
Insurance

[
[
[
[
[
[
[
[

]
]
]
]
]
]
]
]

Investment Contract(s)
Money Market Fund(s)
Mutual Fund(s)
No Product
Options
Penny Stock(s)
Unit Investment Trust(s)
Other _________________

Other Product Type:

5.

Formal Action was brought in (include name of Federal, State or Foreign Court, Location of Court – City or County and
State or Country, Docket/Case Number):

6.

Control Affiliate Employing Firm when activity occurred which led to the civil judicial action (if applicable):

7.

Describe the allegations related to this civil action. (The information must fit within the space provided.):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

8.

Current Status?

[ ] Pending

[ ] On Appeal

9.

If on appeal, action appealed to (provide name of court):

[ ] Final
Date Appeal Filed (MM/DD/YYYY):

_____________________________________________________________________________________________
10.

If pending, date notice/process was served (MM/DD/YYYY)
If not exact, provide explanation:

[ ] Exact

[ ] Explanation

Copy to Jack Habert, 12/28/201

CIVIL JUDICIAL ACTION DISCLOSURE REPORTING PAGE (SBSE-A)
(continuation)
If Final or On Appeal, complete all items below. For Pending Actions, complete Item 14 only.
11.

How was matter resolved: (check appropriate item)
[ ] Consent
[ ] Dismissed

[ ] Judgement Rendered
[ ] Opinion

[ ] Settled

[ ] Withdrawn

[ ] Other _______________________

3.

12.

Resolution Date (MM/DD/YYYY)

[ ] Exact

[ ] Explanation

If not exact, provide explanation:
13.

Resolution Detail
A. Were any of the following Sanctions Ordered or Relief Granted? (Check all appropriate items):
[ ] Monetary/Fine
Amount $________
B.

[ ] Revocation/Expulsion/Denial
[ ] Censure

[ ] Disgorgement/Restitution

[ ] Cease and Desist/Injunction

[ ] Bar

[ ] Suspension

Other
Sanctions:

C. Sanction Detail: If suspended, enjoined or barred, provide duration including start date and capacities affected
(General Securities Principal, Financial Operations Principal, etc.). If requalification, by exam/retraining was a
condition of the sanction, provide length of time given to re-qualify/retrain, type of exam required and whether
condition has been satisfied. If disposition resulted in a fine, penalty, restitution, disgorgement or monetary
compensation, provide total amount, portion levied against prinicpal, date paid and if any portion of penalty was
waived.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
14.

Provide a brief summary of details related to action(s), allegation(s), disposition(s), and/or finding(s) disclosed above.
(The information must fit within the space provided.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

BANKRUPTCY / SIPC DISCLOSURE REPORTING PAGE (SBSE-A)

GENERAL INSTRUCTIONS
This Disclosure Reporting Page [DRP (SBSE-A)] is an an [ ] INITIAL OR [ ] AMENDED response to report details for
affirmative responses to Questions I on Schedule D of Form SBSE-A;
Check [√] item(s) being responded to:
l In the past ten years has the principal ever been a securities firm or a control affiliate of a securities firm that:
[ ] (1) has been the subject of a bankruptcy petition?
[ ] (2) has had a trustee appointed or a direct payment procedure initiated under the Securities Investor
Protection Act?
Use a separate DRP for each event or proceeding. An event or proceeding may be reported for more than one person or
entity using one DRP. File with a completed Execution Page.
It is not a requirement that documents be provided for each event or proceeding. Should they be provided, they will not be
accepted as disclosure in lieu of answering the questions on this DRP.
If a principal is an individual or organization registered through CRD, such principal need only complete Part I of the
applicant’s appropriate DRP (SBSE-A). Details of the event must be submitted on the principal’s appropriate DRP (BD) or
DRP (U-4). If a principal is an organization not registered through the CRD, provide complete answers to all the items on the
applicant’s appropriate DRP (SBSE-a). The completion of this DRP does not relieve the prinicpal of its obligation to update its
CRD records.

PART I
A.

If the principal is registered with the CRD, provide the CRD number. If not, indicate “non-registered” by checking the
appropriate checkbox.
Name of Principal
CRD NUMBER

Registered:

[ ] Yes

[ ] No

[ ] This DRP should be removed from the SBS Entity’s record because the principal is no longer associated with the
SBS Entity.
B.

If the principal is registered through the CRD, has the principal submitted a DRP (with Form U-4) or DRP (BD) to the
CRD System for the event?
If the answer is “Yes,” no other information on this DRP must be provided: If “No,” complete Part II.

[ ] Yes
[ ] No

Note: The completion of this Form does not relieve the principal of its obligation to update its CRD records.

PART II
1.

2.

Action Type: (check appropriate item)

[ ] Bankruptcy
[ ] Declaration
[ ] Compromise
[ ] Liquidated

[ ] Receivership

[ ] Other ____________________

Action Date (MM/DD/YYYY) ______________________

[ ] Exact

[ ] Explanation

If not exact, provide explanation: _____________________________________________________________

Copy to Jack Habert, 12/28/201

BANKRUPTCY / SIPC DISCLOSURE REPORTING PAGE (SBSE-A)
(continuation)
3.

If the financial action relates to an organization over which the applicant or the control affiliate exercise(d) control,
enter organization name and the applicant’s or control affiliate’s position, title or relationship:
________________________________________________________________________________________
Was the Organization investment-related?

4.

[ ] Yes

[ ] No

Court action brought in (Name of Federal, State or Foreign Court), Location of Court (City or County and State or
Country), Docket/Case Number and Bankruptcy Chapter Number (if Federal Bankruptcy Filing):
________________________________________________________________________________________

5.

Is action currently pending?

6.

If not pending, provide Disposition Type: (check appropriate item)

7.

[ ] Yes

[ ] No

[ ] Direct Payment Procedure

[ ] Dismissed

[ ] Satisfied/Released

[ ] Discharged

[ ] Dissolved

[ ] SIPA Trustee Appointed

Disposition Date (MM/DD/YYYY): _______________________

[ ] Exact

[ ] Other _____________
[ ] Explanation

If not exact, provide explanation: _____________________________________________________________
8.

Provide a brief summary of events leading to the action and if not discharged, explain. (The information must fit
within the space provided.):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

9.

If a SIPA trustee was appointed or a direct payment procedure was begun, enter the amount paid or agreed to be
paid by you; or the name of the trustee:

Currently open?

[ ] Yes

[ ] No

Date Direct Payment Initiated/Filed or Trustee Appointed (MM/DD/YYYY): __________ [ ] Exact [ ] Explanation
If not exact, provide explanation: _________________________________________________________________
10.

Provide details of any status/disposition. Include details of creditors, terms, conditions, amounts due and settlement
schedule (if applicable). (The information must fit within the space provided.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________