Form G-FIN-4 Disclosure Form for Person Associated with a Financial I

FORM G-FIN-4

OMB #3064-0093

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

Expires: 12/31/15
Page 1 of 6

1. Applicant Name
Last

First

Middle (If none, so specify)

2. Financial Institution Government Securities Broker or Dealer:
A. Name
B. Registration Number
C. Main Address
3. Office of Employment of Applicant
4. Date of Employment of Applicant
5. To Be Filed With The Following (Indicate One):
Board of Governors of the Federal Reserve System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Comptroller of the Currency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Federal Deposit Insurance Corporation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Securities and Exchange Commission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. It is anticipated that the applicant will perform the following functions in the capacity indicated:

Capacity
Supervisory
Non-Supervisory

A. Underwriting, trading or sales of government securities:
B. Financial advisory or consultant services for issuers in connection with the issuance of
government securities:
C. Research or investment advice, other than general economic information or advice, with
respect to government securities in connection with the activities described in (A) and (B)
above:
D. Activities other than those specifically mentioned which involve communication, directly or
indirectly, with public investors in government securities in connection with the activities
described in (A) and (B) above:
E. Processing and clearance activities with respect to government securities:
F. Maintenance of records involving activities described in (A) through (E) above:

N/A
N/A

7. For the purpose of verifying the information furnished on this form 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.
Employer

Name and Position of Person Contacted

Date

Print Name of Supervisor of Applicant

Signature of Supervisor of Applicant

PERSONAL HISTORY OF APPLICANT
9.

8.
Last Name

First

Social Security Number (Completion is not mandatory)

Middle

11.

10.

City

Resident Street Address

12.

13.
Date of Birth

14. Any other name ever used or by which known:

Place of Birth

State

ZIP Code

Page 2 of 6
15. Employment History
The following is a complete, consecutive statement of all my business connections for the past ten years starting with my current position:
Name of Employer, Complete
Address and Type of Business

From
Mo. Yr.

To
Mo. Yr.

Position
Held

Reason for
Leaving

Full or
Part Time

16. Residential History
The following is a complete, consecutive statement of all my residential addresses for the past five years starting with my current residential address:

Address (Street, City, State, ZIP Code)

From
Mo.
Yr.

To
Mo.

Yr.

IF THE ANSWER TO ANY OF THE FOLLOWING QUESTIONS IS YES, ATTACH COMPLETE DETAILS
17. Definitions
• Investment or Investment-Related - Pertaining to securities, commodities, banking, insurance, or real estate (including, but not limited to acting
as or being associated with a government securities broker or dealer, municipal securities dealer, broker-dealer, investment company,
investment adviser, futures sponsor, bank, or savings and loan association).
• Involved - Doing an act or aiding, abetting, counseling, commanding, inducing, conspiring with or failing reasonably to supervise another in
doing an act.
• Foreign Financial Regulatory Authority - Includes any (a) foreign securities authority; (b) other governmental body or foreign equivalent of a selfregulatory organization empowered by a foreign government to administer or enforce its laws relating to the regulation of investment or
investment-related activities; or (c) membership organization, a function of which is to regulate the participation of its members in the activities
listed above.
A. Have you, within the 10 years preceding the date of this filing, been convicted of or plead guilty or nolo contendere (“no contest”) in a domestic
or foreign court to:
(1) a felony or misdemeanor involving: investments or an investment-related business, fraud, false statements or omissions,
wrongful taking of property, or bribery, forgery, counterfeiting or extortion? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
(2) any other felony? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
B. Has any domestic or foreign court ever:
(1) enjoined you in connection with any investment-related activity? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
(2) found that you were involved in a violation of investment-related statutes or regulations? . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
C. Has the U.S. Securities and Exchange Commission or the Commodity Futures Trading Commission ever:
(1) found you to have made a false statement or omission? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
(2) found you to have been involved in a violation of investment-related regulations or statutes? . . . . . . . . . . . . . . . . . . . . . . . Yes
No
(3) found you to have been a cause of an investment-related business having its authorization to do
business denied, suspended, revoked, or restricted? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
(4) entered an order denying, suspending or revoking your registration or disciplined you by
restricting your activities? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
(5) imposed a civil money penalty on you, or ordered you to cease and desist from any activity? . . . . . . . . . . . . . . . . . . . . . . . Yes
No
D. Has any other federal regulatory agency, any state regulatory agency, or foreign financial regulatory authority ever:
(1) found you to have made a false statement or omission or been dishonest, unfair or unethical? . . . . . . . . . . . . . . . . . . . . . Yes
No
(2) found you to have been involved in a violation of investment regulations or statutes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
(3) found you to have been a cause of an investment-related business having its authorization to do
business denied, suspended, revoked, or restricted? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
(4) entered an order against you in connection with investment-related activity? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
(5) denied, suspended, or revoked your registration or license or otherwise prevented you from
associating with an investment related business, or disciplined you by restricting your activities? . . . . . . . . . . . . . . . . . . . Yes
No
(6) revoked or suspended your license as an attorney, accountant or federal contractor? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
E. Has any self-regulatory organization or commodities exchange:
(1) found you to have made a false statement or omission? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
(2) found you to have been involved in a violation of its rules? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
(3) found you to have been the cause of an investment-related business having its authorization to do
business denied, suspended, revoked or restricted? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
(4) disciplined you by expelling or suspending you from membership, barring or suspending your association with its
members, or restricting your activities? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
F. Has any foreign government, court, regulatory agency, or exchange ever entered an order against you
related to investments or fraud other than as reported in items 17.A., B., or D.? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No

Page 3 of 6

G. Are you now the subject of any complaint, investigation, or proceeding that could result in a
“yes” answer to parts A-F of this item? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
H. Have you been discharged or permitted to resign because you were accused of:
(1) violating investment-related statutes, regulations, rules, or industry standards of conduct? . . . . . . . . . . . . . . . . . . . . . . . . .
(2) fraud or the wrongful taking of property? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(3) failure to supervise in connection with investment-related statutes, regulations, rules or industry
standards of conduct? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date

Yes

No

Yes
Yes

No
No

Yes

No

Signature of Applicant

FORM G-FIN-4 ACKNOWLEDGMENT
18. Applicant Name

19. Financial Institution Government Securities Broker or Dealer Name

20. Financial Institution Government Securities Broker or Dealer Address

Receipt Stamp

21. Attention:

WHEN THE FORM G-FIN-4 IS RECEIVED BY THE APPROPRIATE REGULATORY AGENCY, THIS ACKNOWLEDGMENT WILL
BE STAMPED TO SHOW RECEIPT AND RETURNED TO THE PERSON NAMED IN ITEM 21. THE STAMPED
ACKNOWLEDGMENT SHOULD BE RETAINED TO SUBSTANTIATE FILING.

Public reporting burden for this collection of information is estimated to average 2 hours per
response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any aspect of this collection of information,
including suggestions for reducing this burden to: FDIC Paperwork Reduction Act Clearance
Officer, MB-3016, 17th Street, N.W., Washington, DC 20429; and to the Office of Management and
Budget, (1535-0089) Washington, DC 20503.

G-FIN-4
Page 4 of 6
PRIVACY ACT NOTICE FOR FORM G-FIN-4
(To accompany Form G-FIN-4)
GENERAL
This information is provided in accordance with the Privacy Act of 1974, 5 USC 552a, to those applicants completing a
Form G-FIN-4 (Disclosure Form for Persons Associated with a Financial Institution Government Securities Broker or
Dealer) which is to be filed with the appropriate regulatory agency, as defined in section 3(a)(34)(G) of the Securities
Exchange Act of 1934 (15 USC 78c(a)(34)(G)).
AUTHORITY
Section 15C(b)(1) of the Securities Exchange Act of 1934 (15 USC 78o-5(b)(1)).
PURPOSE
The appropriate regulatory agency will review the information reported on Form G-FIN-4 for the purpose of determining
whether the applicant might be subject to disciplinary action pursuant to section 15C(c)(2) of the Securities Exchange Act
of 1934 (15 USC 78o-5(c)(2)).
EFFECTS OF NONDISCLOSURE
Except for persons who have a current Form U-4 or Form MSD-4 on file with their financial institution, persons who are or
seek to be associated with a financial institution government securities broker or dealer are required to disclose the
information necessary to complete Form G-FIN-4, except that disclosure of Social Security numbers is voluntary. Failure
to disclose the necessary information may make an applicant subject to limitations on his or her activities with the
financial institution government securities broker or dealer.
ROUTINE USES
The appropriate regulatory agencies regard the information provided by each respondent on this form as confidential.
However, the information reported on Form G-FIN-4 may be routinely used by the appropriate regulatory agency as
follows:
1. To refer to the appropriate governmental authority, whether Federal, state, local or foreign, or to the appropriate selfregulatory organization, such information as may indicate a violation or potential violation of law, regulation, or rule.
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:
a. In which the Federal securities, banking or commodities laws are at issue:
b. In which the propriety of any disclosure of information reported on Form G-FIN-4 is at issue; or
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.
4. To disclose to a Federal, state, local or foreign governmental authority or self-regulatory organization such
information as may be necessary to obtain from such authority or organization additional information concerning the
associated person.
5. To disclose such information as may be necessary to respond to a request from a Federal, state, local or foreign
governmental authority or self-regulatory organization for information needed in connection with the issuance of a
license, granting of a benefit, or similar action affecting the associated person.
6. To disclose such information as may be necessary to respond to any congressional inquiry made at the request of
the associated person.

G-FIN-4
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INSTRUCTIONS FOR COMPLETING AND FILING FORM G-FIN-4
GENERAL INSTRUCTIONS
1. As used in these instructions and Form G-FIN-4:
a. The term financial institution government securities broker or dealer means a government securities broker or
dealer that is a financial institution and that is not exempt from regulation as a government securities broker or
dealer under Part 401 of Title 17, Code of Federal Regulations.
b. The terms applicant and person associated with a financial institution government securities broker or dealer
mean a person, other than a person whose functions are solely clerical or ministerial, who is directly engaged in
any of the following activities in either a supervisory or non-supervisory capacity: (i) underwriting, trading or sales
of government securities; (ii) financial advisory or consultant services for issuers in connection with the issuance
of government securities; (iii) research or investment advice, other than general economic information or advice,
with respect to government securities in connection with the activities described in clauses (i) and (ii); (iv)
activities other than those specifically mentioned which involve communication, directly or indirectly, with public
investors in government securities in connection with the activities described in clauses (i) and (ii) above. In
addition, the term includes anyone directly engaged in the following activities in a supervisory capacity: (i)
processing and clearance activities with respect to government securities and (ii) maintenance of records
involving any of the activities described in this paragraph (b).
Persons who function solely in a fiduciary capacity and persons whose sole government securities activities
are, without exercising any investment discretion and solely at the direction of customers, to receive and/or
transmit customer orders to purchase or sell government securities, but who do not give investment advice or
receive transaction-based compensation, are not “associated persons” and are not required to file this form.
Directors and senior officers of the financial institution who may from time to time set broad policy guidelines
affecting the financial institution as a whole that are not directly related to the conduct of the financial institution’s
government securities business are not considered to be “directly engaged” in the activities described in this
paragraph and are not required to file this form.
2. Form G-FIN-4 is to be used by financial institution government securities brokers and dealers and persons who are
or seek to be associated persons of such brokers or dealers to comply with the rules of the Federal Deposit
Insurance Corporation, 17 CFR 400.4, which require the filing and keeping current of the Form G-FIN-4. This form
is required only when a current Form U-4 or MSD-4 for the applicant is not on file with the financial institution and
its appropriate regulatory authority.
3. Financial institution government securities brokers and dealers are required to file Form G-FIN-4 with the
appropriate regulatory agency as set forth below:
a. The Comptroller of the Currency in the case of a national bank, a bank in the District of Columbia examined by
the Comptroller of the Currency, or a Federal Branch or Federal agency of a foreign bank (as such terms are
used in the International Banking Act of 1978);
b. The Board of Governors of the Federal Reserve System, in the case of a state member bank of the Federal
Reserve System, a foreign bank, an uninsured state branch or state agency of a foreign bank, a commercial
lending company owned or controlled by a foreign bank (as such terms are used in the International Banking Act
of 1978), or a corporation organized or having an agreement with the Board of Governors of the Federal Reserve
System pursuant to section 25 or section 25A of the Federal Reserve Act;
c. The Federal Deposit Insurance Corporation, in the case of a bank insured by the Federal Deposit Insurance
Corporation (other than a member of the Federal Reserve System or a Federal savings bank) or an insured state
branch of a foreign bank (as such terms are used in the International Banking Act of 1978); and
e. The Securities and Exchange Commission, in the case of all other financial institution government securities
brokers and dealers.
4. Copies of Form G-FIN-4 may be obtained from any of the appropriate regulatory agencies listed in instruction 3.

G-FIN-4
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5. An original and three copies of Form G-FIN-4 are to be filed by the applicant with the financial institution government
securities broker or dealer, which will in turn file the original and two copies with the appropriate regulatory agency
listed in instruction 3. The applicant is responsible for keeping the form current by filing, within 30 days after the
occurrence of any event that makes the information in the currently filed form incomplete or incorrect, an original and
three copes of a statement showing the changed information in a form acceptable to the appropriate regulatory
agency. The financial institution government securities broker or a dealer will retain the third copy of a complete
form, including all updates, in its records for a least three years after the applicant’s employment or other association
with the government securities broker and/or dealer function of the financial institution has terminated,
or after a Form G-FIN-5 has been filed, whichever is later.
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 by 11
inch paper. 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 applicant and the financial institution
government securities broker or dealer should appear on every attachment sheet.
7. Form G-FIN-4 and any attachments may be duplicated by any method which produces legible copies of type size
identical to that of the Form G-FIN-4 on white 8-1/2 by 11 inch paper.
8. Form G-FIN-4 shall be manually signed on page one by the supervisor of the applicant and on page three by the
applicant.
9. All items on Form G-FIN-4 are to be completed, except that disclosure of one’s Social Security number is not
mandatory. The date on which the Form G-FIN-4 is received by the appropriate regulatory agency shall be the date
of filing. A Form G-FIN-4 which is not prepared and executed in accordance with the applicable requirements may
be returned as unacceptable for filing. Acceptance for filing shall not constitute any finding that a Form G-FIN-4 has
been completed in accordance with those requirements or that any information reported on the form is true, correct,
complete, or not misleading.
INSTRUCTIONS TO SPECIFIC ITEMS ON FORM G-FIN-4
10. Items 2 through 7 are to be completed by the financial institution government securities broker or dealer employing
or proposing to employ the applicant named in item 1. All other items are to be completed by the applicant.
11. Item 3: Give the address of the office of the financial institution government securities broker or dealer in which the
applicant is or will be employed.
12. Item 5: Indicate the appropriate regulatory agency as set forth in instruction 3.
13. Items 15 and 16: All time periods must be accounted for.
14. Item 17(a): Although this item relates only to convictions during the past 10 years, it should be noted that section 19
of the Federal Deposit Insurance Act (12 USC 1829) prohibits any insured bank, except with the written consent of
the Federal Deposit Insurance Corporation, from employing any person who has ever been convicted of a criminal
offense involving dishonesty or breach of trust.