Form G-FIN-5 Uniform Termination Notice for Persons Associated with a

FORM G-FIN-5
Uniform Termination Notice for Person Associated with a
Financial Institution Government Securities Broker or Dealer

OMB #3064-0093
Expires: 12/31/15
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1. Individual’s Name
Last

First

Middle (If none, so specify)

2. Capacity
3. Social Security Number
4. Financial Institution Government Securities Broker or Dealer:
a. Name
b. Registration Number
c. Main Address

5. Office of Employment Address

6. Date Terminated
7. Reason for Termination - Check One:
Resigned*

Discharged*

Deceased

Transfer*

Other*

*Furnish full details on attached sheet if related to a violation or probable violation of banking or securities law.
8. While associated, was the individual the subject of any investigation, proceeding, disqualification or disciplinary action by any governmental agency
pursuant to Section 15C of the Securities Exchange Act of 1934 (15 U.S.C. 78o-5)?
No
**Yes
**Furnish full details on attached sheet.

Date

Print Name of Supervisor of Individual

Signature of Supervisor of Individual

Person to Contact for Further Information
ACCEPTANCE OF THIS FORM FOR FILING SHALL NOT CONSTITUTE ANY FINDING THAT THE INFORMATION SUBMITTED HEREIN IS TRUE,
CURRENT, COMPLETE, OR NOT MISLEADING. INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT MAY CONSTITUTE FEDERAL
CRIMINAL VIOLATIONS. (See 18 U.S.C. 1001 and 1005, and 15 U.S.C. 78ff.)

FORM G-FIN-5 ACKNOWLEDGEMENT
Receipt Stamp
9. Name of Individual
10. Financial Institution Broker or Dealer Name
11. Financial Institution Broker or Dealer Address

12. Attention
WHEN THE FORM G-FIN-5 IS RECEIVED BY THE APPROPRIATE REGULATORY AGENCY, THIS ACKNOWLEDGEMENT WILL BE STAMPED TO
SHOW RECEIPT AND RETURNED TO THE PERSON NAMED IN ITEM 12. THE STAMPED ACKNOWLEDGEMENT SHOULD BE RETAINED TO
SUBSTANTIATE FILING.

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INSTRUCTIONS FOR COMPLETING AND FILING FORM G-FIN-5
GENERAL INSTRUCTIONS
This report is required by Section 15C of the Securities Exchange Act of 1934 (15 U.S.C. 78 o-5) and the regulations
thereunder, 17 CFR 400.4. The Department of the Treasury and the appropriate regulatory agencies, as defined below,
regard the information provided by each respondent as confidential.

1. As used in these instructions and Form G-FIN-5:
a. The term financial institution government securities broker or dealer means a government securities broker or
dealer that is a financial institution and that has not been exempted from regulation as a government securities
broker or dealer under Part 401 of Title 17, Code of Federal Regulations; and
b. The term person associated with a financial institution government securities broker or dealer means a person,
other than a person whose functions are solely clerical or ministerial, who is 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. The term also
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-5 is to be used by financial institution government securities brokers and dealers to report the
termination of association of a person with the financial institution government securities broker or dealer as provided
in the rules of the Department of the Treasury, 17 CFR 400.4.
This form should be used only when a Form U-5 or MSD-5 has not been filed with respect to such person.
Termination includes transfer of an individual to another position in the financial institution that does not involve the
individual in the activities included in the definition of person associated with a financial institution government
securities broker or dealer.
3. Financial institution government securities brokers and dealers are required to file Form G-FIN-5 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;

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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
d. The Securities and Exchange Commission, in the case of all other financial institution government securities
brokers and dealers.
4. Copies of Form G-FIN-5 may be obtained from any of the appropriate regulatory agencies listed in instruction 3.
5. An original and two copies of Form G-FIN-5 and any attachments are to be filed by the financial institution
government securities broker or dealer with the appropriate regulatory agency listed in instruction 3 within 30 days
after termination of the association of the individual named in item 1, except that (i) if the financial institution notifies
the appropriate regulatory agency that the individual will remain in the financial institution’s employment and the
financial institution continues to update information about such person as provided in 17 CFR 400.4(b), the Form GFIN-5 need not be filed until within 30 days after the termination of the individual’s employment with the financial
institution, and (ii) if the financial institution is required to and has filed a Form U-5 or MSD-5 with respect to such
person, the Form G-FIN-5 need not be filed. A financial institution government securities broker or dealer filing a
Form G-FIN-5 shall retain an exact copy in its records for at least three years following its filing.
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-5 and any attachments may be duplicated by any method which produces legible copies of type size
identical to that of the Form G-FIN-5 on white 8-1/2 by 11 inch paper.
8. Form G-FIN-5 shall be manually signed by the supervisor of the person named in item 1.
9. All items on Form G-FIN-5 are to be completed, except that disclosure of the individual’s Social Security number is
not required if that information is unavailable. The date on which the Form G-FIN-5 is received by the appropriate
regulatory agency shall be the date of filing. A Form G-FIN-5 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-5 has been completed in accordance with those requirements or that any information
reported on the form is true, correct, complete, or not misleading.

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, (3064-0093) Washington, DC
20503.