Form 1534 Form MSD

UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

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FORM MSD
APPLICATION FOR REGISTRATION AS A MUNICIPAL SECURITIES DEALER

PURSUANT TO RULE 15Ba2-1 UNDER THE SECURITIES EXCHANGE ACT OF 1934

OR AMENDMENT TO SUCH APPLICATION

GENERAL INSTRUCTIONS

A. Use of Form
This form is to be used by a bank or a separately identifiable department or division of a bank (as defined by the Municipal Securities
Rulemaking Board) to apply for registration as a municipal securities dealer with the Securities and Exchange Commission pursuant to
section 15B(a) of the Securities Exchange Act of 1934 (the “Act”), or to amend such application. If applicant is a department or division
of a bank, the application or amendment shall be deemed to have been made by the bank on behalf of the applicant.
B. Presentation of Information
All information required by Form MSD must be submitted in typewritten or printed manner on the prescribed form or mechanical
reproductions thereof. The execution page on each copy of the form must contain an original manual signature of the appropriate duly
authorized individual. Mechanical reproductions of signatures for this purpose are not acceptable. All other pages containing correct
information may be mechanically reproduced by any method producing clear, legible copies of identical type size. Retain one exact copy
for your records.
Additional copies of Form MSD are available from the Securities and Exchange Commission, Washington, D.C. 20549.
C. Signature
Form MSD shall be signed in the name of the applicant by a principal officer of the applicant or, if applicant is a department or
division of a bank, by a principal officer of the bank, in each case duly authorized to sign this Form, who is directly engaged in the
management, direction or supervision of the applicant’s municipal securities dealer activities.
D. Additional Space
If the space provided for any answer on Form MSD, other than the Schedules to the Form, is insufficient, the answer may be
completed on an additional sheet attached to the Form and appropriately identified.
E. Names
Individuals’ names, except for executing signatures, shall be given in full wherever required (last name, first name, middle name).
The full middle name is required. Initials are not acceptable unless the individual legally has only an initial. If so,indicate this after the
initial.
F. Acceptance for Filing
A Form MSD which is not prepared and executed in compliance with applicable requirements may be returned as not acceptable
for filing. However, acceptance of this Form shall not constitute any finding that it has been filed as required or that the information
submitted is true, current, or complete.
G. General Definitions
a. Unless the context clearly indicates otherwise or unless otherwise specified in these instructions, all terms used in Form MSD have
the same meaning as in the Act and the General Rules and Regulations of the Securities and Exchange Commission. In particular, the
terms “self-regulatory organization,” “rules of a self-regulatory organization,” “municipal securities,” “municipal securities dealer,”
“person associated with a municipal securities dealer,” “municipal securities investment portfolio,” “appropriate regulatory agency,”
and “records” shall have the respective meanings set forth in sections 3(a)(26), 3(a)(28), 3(a)(29), 3(a)(30), 3(a)(32), 3(a)(33),
3(a)(34), and 3(a)(37) of the Act.
b. Jurisdiction — The term “jurisdiction” means a state, a territory, the District of Columbia, the Commonwealth of Puerto Rico, or any
SEC1534 (02-08)

Persons who are to 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.

subdivision or regulatory body thereof.
c. Person — The term “person” includes a corporation, partnership, other organization, trust and estate, as well as natural person.
d. Municipal securities dealer activities — The term “municipal securities dealer activities” has the meaning set forth in Municipal
Securities Rulemaking Board rule G-1(b), which defines the terms “separately identifiable department or division of a bank” for
purposes of Section 3(a)(30) of the Securities Exchange Act of 1934.
H. Amendments
The information contained in Form MSD is of a continuing nature and must be updated or amended periodically in the event
any of the information previously submitted to the Commission becomes incomplete or inaccurate. Where an item is being amended,
only those items which are being amended or which have changed since the previous filing need to be filed, except that a completed
page one and a completed execution page, manually signed, must be filed with each amendment. WHEN ANY ITEM ON A PAGE
IS AMENDED, IT IS NECESSARY TO ANSWER IN FULL ALL OTHER ITEMS ON THE PAGE BEING AMENDED.
I. Items Not Applicable
If Form MSD is being filed as an application for registration, all applicable items must be answered in full. If any item is not
applicable, indicate by “none” or “N/A” as appropriate.
J. Schedules to Form
Each Schedule to Form MSD is deemed to be a part of the Form.
K. Filing of Form
Form MSD must be filed in triplicate with the Securities and Exchange Commission, Washington, D.C. 20549. The execution
page of each copy shall contain an original manual signature. In addition, an original signed copy of the Form must be filed with
the applicant’s appropriate regulatory agency, determined in accordance with section 3(a)(34) of the Act. Applicants which are
national banks, or departments or divisions of such banks, must file Form MSD with the Comptroller of the Currency, Credit &
Market Risk, 250 E Street, SW, MS 9-14, Washington, D.C. 20219; applicants which are State member banks of the Federal Reserve
System, or departments or division of such banks, must file Form MSD with the Board of Governors of the Federal Reserve System,
Risk Policy Section, Mail Stop 1810, 20th and C Streets, NW, Washington, D.C. 20551; applicants which are banks insured by
the Federal Deposit Insurance Corporation (other than members of the Federal Reserve System), or departments or divisions
of such banks, must file Form MSD with the Federal Deposit Insurance Corporation, 550 17th Street, NW,Washington, D.C.
20429; applicants which are federal saving associations, or departments or divisions of such savings associations, must file
Form MSD with the Office of Thrift Supervision, Assistant Managing Director, Examinations and Supervision Policy, 1700 G
Street, NW, Washington, D.C. 20552.
L. Instructions to Specific Items
a. Item 1(a) — If the applicant is not registered currently with the Commission and is not succeeding to and continuing the business
of another registered municipal securities dealer, the box marked “a new application” should be checked. If a registered municipal
securities dealer is amending items on a currently effective Form MSD, the box marked “an amendment” should be checked. If
the applicant is succeeding to and continuing the business of another registered municipal securities dealer, the box marked “a
successor application” should be checked. If a bank registered as a municipal securities dealer determines it would prefer to
register as a separately identifiable department or division, or the converse, it is necessary that (i) the applicant file a Form MSD,
indicating in Item 1 that it is a “successor application” and (ii) the currently registered entity file a Form MSDW to withdraw its
registration. Pursuant to Securities Exchange Act Rule 15Ba2-4, 17 CFR 240.15Ba2-4, if a municipal securities dealer succeeds
to and continues the business of another registered municipal securities dealer, the registration of the predecessor shall be deemed
to remain effective as the registration of the successor for a period of 75 days after such succession, provided that a Form MSD
is filed by such successor within 30 days after such succession.
b. Items 2(a) and 2(b) — If applicant is a department or division of a bank, these items should be answered only for applicant, rather
than for the bank. Information with respect to the bank of which applicant is a part must be given in response to item 2(d).
c. Item 5 — This item calls for information concerning persons directly engaged in the supervision of any of the applicant’s
municipal securities dealer activities. A separate Schedule A or Form MSD-4 (which may be obtained from the appropriate
regulatory authority) must be completed for each person named in response to Item 5.
d. Item 6 — This item calls for information concerning persons not named in item 5 who may nevertheless directly or indirectly
control any of applicant’s municipal securities dealer activities. Such control may be exercised through stock ownership,
agreement or otherwise. Generally a person will be deemed to be in direct or indirect control of applicant’s municipal securities
dealer activities if such person exercises or has the ability to exercise a controlling influence over the management or policies
of applicant with respect to any of applicant’s municipal securities dealer activities. Depending on the fact of a particular situation,
senior officers or directors of the applicant or of the bank of which applicant is a part, or of a parent bank holding company, may
be deemed to be in direct or indirect control of such activities. Schedule A is not required for any person named in response to
2

item 6, but information is required to be furnished on Schedule B for each such person.
e. Item 7 — The information required by this item must be furnished with respect to each person directly or indirectly engaged in
or controlling any of the applicant’s municipal securities dealer activities, including any employee.
f. Item 9 — This item relates to services performed by persons other than applicant with respect to applicant’s municipal securities
dealer activities. There need not be furnished in response to this item information concerning personnel, payroll and other
administrative services which are not directly related to the applicant’s municipal securities dealer activities.
M. Privacy Act Statement
Under Section 15, 15B(a), 17(a) and 23(a) of the Securities Exchange Act of 1934 and the Rules and Regulations thereunder,
the Commission is authorized to solicit the information required to be supplied by this form from applicants for registration as a
municipal securities dealer (and persons associated with applicants). Disclosure of the information specified on this form is
mandatory prior to processing of applications for registration as a municipal securities dealer, except social security numbers,
disclosure of which is voluntary. The information will be used for the principal purpose of determining whether the Commission
should grant or deny registration to the applicant; social security numbers, if furnished, will be used only to assist the Commission
in identifying applicants and, therefore, in promptly processing applications. Information supplied on this form will be included
routinely in the public files of the Commission and will be available for inspection by any interested person. A form which is not
prepared and executed in compliance with applicable requirements may be returned as not acceptable for filing. Acceptance of this
form, however, shall not constitute any finding that it has been filed as required or that the information submitted is true, current
or complete. Intentional misstatements or omissions of fact constitute federal criminal violations. [See 18 U.S.C. 1001 and 15
U.S.C. 78ff(a)].

3

APPLICATION FOR REGISTRATION AS A
MUNICIPAL SECURITIES DEALER PURSUANT TO RULE 15Ba2-1
UNDER THE SECURITIES EXCHANGE ACT OF 1934
OR AMENDMENT TO SUCH APPLICATION

OFFICIAL USE

GENERAL: Form MSD is to be used by a bank or a separately identifiable department or division of a bank (as defined by the
Municipal Securities Rulemaking Board) to apply for registration as a municipal securities dealer with the Securities and Ex­
change Commission pursuant to section 15B(a) of the Securities Exchange Act of 1934 (the “Act”) or to amend such applica­
tion. If applicant is a department or division of a bank, the application or amendment shall be deemed to have been made by the
bank on behalf of the applicant. Read all instructions before preparing the Form. If this Form is filed as an amendment, only a
completed page one, a completed and signed execution page, and those items which are being amended or which have changed
since the previous filing need to be filed. Please print or type all responses
IN COMPLIANCE WITH THE APPLICABLE SECURITIES LAWS,

THE APPLICANT HEREBY SUBMITS THE FOLLOWING INFORMATION:

1.

(a) This Form is filed with the Securities and Exchange Commission as:
A new application
An amendment
A successor application
(b) Applicant is a:
Bank

2.
[See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a)]

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS

FORM MSD
Page 1

Department or Division of a Bank

(a) Name of applicant:
Full name of applicant: _____________________________________________________________________________________
Name under which municipal securities dealer activities are conducted, if different: ________________________________
____________________________________________________________________________________________________________
If name of applicant is hereby amended, state name under which registered previously: __________________________
____________________________________________________________________________________________________________
If name under which municipal securities dealer activities are conducted is hereby amended, state name given
previously: _______________________________________________________________________________________________
(b) Address and telephone number of principal office at which applicant’s municipal securities dealer activities are

conducted:

______________________________________________________________________________________________________________________________
Address of principal office:
Number and Street
City
State
Zip Code
________________________________________________________________________________________________________________________________
Mailing address if different:
Number and Street
City
State
Zip Code
Telephone Number: ___________________________________________________________

Area Code

Telephone Number

ALL OF THE ITEMS ON THIS PAGE MUST BE ANSWERED AND COMPLETED IN FULL

DO NOT WRITE BELOW THIS LINE . . . . FOR OFFICIAL USE ONLY
GEO. CODE

FILING DATE

BANK DIV.

MAIL CODE

4

EFFECTIVE DATE

OFFICIAL USE

FORM MSD Page 2
2.

(c) Name, title, mailing address and telephone number of person to contact with respect to applicant’s municipal securities dealer
activities:
__________________________________________________________________________________________________________
Title

__________________________________________________________________________________________________________
Mailing address: Number and Street
City
State
Zip
Code

Telephone Number: ___________________________________________________________________
Area Code

Telephone Number

(d) If applicant is a department or division of a bank, name, principal business address, mailing address, if different, and telephone
number of bank:
Full name of bank: ________________________________________________________________________________________
__________________________________________________________________________________________________________
Address of principal place of business: Number and Street
City
State
Zip Code
[See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a)]

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS

Name

__________________________________________________________________________________________________________
Mailing address if different: Number and Street
City
State
Zip Code
Telephone Number:___________________________________________________________________
Area Code

Telephone Number

(e) Applicant agrees and consents that the notice of any proceeding under the Act involving applicant may be given by sending
such notice by mail or confirmed telegram to the person named, at the address given, in response to item 2(c).
3.

4.

List below each jurisdiction in which applicant, or the bank of which applicant is a part, is filing or has filed an application for
registration or license as a municipal securities dealer or in which applicant, or the bank of which applicant is a part, is so registered
or licensed:
_______________________________________________

____________________________________________________

_______________________________________________

____________________________________________________

_______________________________________________

____________________________________________________

_______________________________________________

____________________________________________________

(a) Indicate whether applicant, or the bank of which applicant is a part, is a national banking association or YES NO
operated under the District of Columbia Code:
(b) If applicant is a bank, the date of applicant’s organization. If applicant is a department or division
of a bank, the date of the bank’s organization: _____________________________________________
(c) If applicant, or the bank of which applicant is a part, is a state-chartered bank, indicate whether
applicant or such bank is:
(1) a member of Federal Reserve System:
(2) if not a member of the Federal Reserve System, insured by the Federal Deposit
Insurance Corporation:

YES NO
YES NO

If any item on this page is amended, you must answer in full all other items on this page and file
with a completed page 1, and signed execution page. No Schedule required by any item on this page
need be filed with an amended item unless the Schedule itself is amended.
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FORM MSD Page 3
5.

Furnish the following information for each person who is directly engaged in the management, direction or supervision of any of
the applicant’s municipal securities dealer activities:
(Place a double asterisk (**) next to the name of each person who is added to the names furnished in the most recent previous filing.)

RELATIONSHIP

Last

First

Middle

Beginning
Date
Mo. Yr.

Title or Status

Official
Use
Only
01
02
03
04
05
06

[See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a)]

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS

FULL NAME

07
08
09
10
11
12
13
14
15
16
17
18
If applicant is a department or division of a bank, place an asterisk (*) next to the name of each person listed above who has been designated
by the board of directors of the bank as responsible for the day-to-day conduct of the bank’s municipal securities dealer activities, including
the supervision of all of the bank’s employees engaged in the performance of such activities.
Complete a separate Schedule A or Form MSD-4 for each person named in response to item 5. If applicant is a department or division of a bank,
attach as an exhibit to this Form a copy of the resolution or resolutions of the board of directors of the bank in which each person identified in
item 5 as having been designated by the board as responsible for the day-to-day conduct of the bank’s municipal securities dealer activities is
so designated. Such resolutions must be certified by an appropriate officer of the bank as having been duly adopted and as true, current, and
complete.

If any item on this page is amended, you must answer in full all other items on this page and file with a
completed page 1, and signed execution page. No Schedule required by any item on this page need be filed
with an amended item unless the Schedule itself is amended.
6

OFFICIAL USE

[See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a)]

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS

FORM MSD Page 4
6.

YES NO
Does any person not named in item 5 directly or indirectly control any of the applicant’s municipal
securities dealer activities? ...........................................................................................................
If “yes,” state on Schedule B the exact name and business (or if none, residence) address of each such person (if
an individual, state last, first and middle names) and describe the basis through which such person directly or
indirectly controls applicant’s municipal securities dealer activities. If applicant is a department or division of a
bank and any such person has been designated by the board of directors of the bank as responsible for the day-to­
day conduct of the bank’s municipal securities dealer activities, so indicate in Schedule B and explain why such
person is not named in item 5.

7.

(a) State whether the applicant, any person named in response to item 5 or 6, or any person directly engaged
in the management, direction, supervision or performance of any of the applicant’s municipal securities dealer
activities, or who directly or indirectly controls any of such activities or who is directly or indirectly controlled
by applicant in connection with any of such activities, including any employee:
(i) Has been found by the Securities and Exchange Commission or an appropriate regulatory agency or any
jurisdiction willfully to have made or caused to be made any statement which was, at the time and in the
light of the circumstances under which it was made, false and misleading with respect to any material fact,
or to have omitted to state any material fact, which was required to be stated, in any application for
registration or report required to be filed under the Federal securities laws or under the securities law of
any jurisdiction, or in any proceeding before the Securities and Exchange Commission or an appropriate
regulatory agency or any jurisdiction relating to securities or the conduct of business or registration as a
broker, dealer, municipal securities dealer or investment adviser or associated person thereof YES NO
..............................................................................................................................................
(ii) Has been convicted within 10 years of any felony or misdemeanor (1) involving the purchase or sale of
any security, the taking of a false oath, the making of a false report, bribery, perjury, burglary, or
conspiracy to commit any such offense; (2) arising out of the conduct of the business of a broker, dealer,
municipal securities dealer, investment adviser, bank, insurance company, or fiduciary; (3) involving the
larceny, theft, robbery, extortion, forgery, counterfeiting, fraudulent concealment, embezzlement, fraudulent
conversion, or misappropriation of funds or securities; or (4) involving the violation of Sections 152, 1341,
1342 or 1343 or Chapters 25 or 47 of Title 18, United States Code (concealment of assets, false oaths and
claims, or bribery, in any bankruptcy proceeding; mail fraud, fraud by wire, including telephone,
telegraph, radio or television; counterfeiting, forgery, fraud, false statements); or has pleaded nolo YES NO
contendere to any such felony or misdemeanor.........................................................
(iii)Is enjoined permanently, or within the past 10 years has been enjoined temporarily, by order, judgment
or decree of any court of competent jurisdiction from acting as an investment adviser, underwriter, broker,
dealer, or municipal securities dealer or as an associated person or employee of any of the foregoing, or
as an affiliated person or employee of any investment company, bank, or insurance company, or from
engaging in or continuing any conduct or practice in connection with any such activity, or in connection
with the purchase or sale of any security, or arising out of any securities or investment advisory YES NO
activities..............................................................................................................................
(iv) Has been found by the Securities and Exchange Commission or an appropriate regulatory agency or any
jurisdiction or any court to have violated or to have aided, abetted, counselled, commanded, induced, or
procured the violation by any other person of the Federal laws, or the laws of any jurisdiction, relating to
securities or relating to the conduct of business as a broker, dealer, municipal securities dealer, investment
adviser, or investment company, any rule or regulation under any of such laws, or any rule of the Municipal
Securities Rulemaking Board, or to have failed reasonably to supervise another person who committed YES NO
such a violation, or to have been unable to comply with any of the foregoing ...................
(v) Has been the subject of an order of the Securities and Exchange Commission entered pursuant to
paragraph (6) of Section 15(b) or paragraph (4) of Section 15B(c) of the Securities Exchange Act of 1934
or an order of a court or jurisdiction, or an order of an appropriate regulatory agency entered pursuant to
paragraph (5) of Section 15B(c) of the Securities Exchange Act of 1934, barring or suspending the right
of such person to be associated with a broker or dealer or municipal securities YES NO
dealer................................................................................................................................................

If any item on this page is amended, you must answer in full all other items on this page and file
with a completed page 1, and signed execution page. No Schedule required by any item on this page
need be filed with an amended item unless the Schedule itself is amended.
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FORM MSD Page 5
(a) (vi) Has been denied membership or registration with, or participation in, or has been suspended, revoked or
expelled from membership, participation in or registration with any self-regulatory organization, or has
been suspended or barred from being associated with any member of a self-regulatory YES NO
organization....................................................................................................................................
(vii) Has been denied registration (license) with, or suspended, revoked or expelled from registration (license)
with the Securities and Exchange Commission or any jurisdiction as a broker, dealer, investment adviser,
securities salesman, or municipal securities dealer, or has been barred from being associated with a YES NO
person engaged in such business ....................................................................................
(viii) Has been found to have been a cause of (1) the denial, suspension, or revocation of any person’s
membership or participation in, or registration with the Securities and Exchange Commission, any
jurisdiction, or any self-regulatory organization, (2) any bar or suspension of any person from being
associated with a broker, dealer, municipal securities dealer, or member of a self-regulatory organization, YES NO
or (3) any expulsion of any person from a self-regulatory organization ..............................................
(ix) Has willfully made or caused to be made any statement which was, at the time and in the light of the
circumstances under which it was made, false and misleading with respect to any material fact, or has
omitted to state any material fact, which was required to be stated, in any application for membership or
participation in, or to become associated with a member of, a self-regulatory organization, in any report
required to be filed with a self-regulatory organization, or in any proceeding before a self-regulatory YES NO
organization ....................................................................................................................

[See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a)]

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS

7.

(x)

Has been, within the past 10 years, the subject of any cease and desist, desist and refrain, prohibition, or
similar order which was issued by the United States or any jurisdiction arising out of the conduct of the YES NO
business of a broker, dealer, municipal securities dealer or investment adviser ............................

(xi) Has been associated at any time as an officer, director, general partner, or owner of 10 percentum or more
of the voting securities, or has at any time directly or indirectly through agreement or otherwise exercised
or had the power to exercise a controlling influence over the management or policies of, a broker or dealer
or municipal securities dealer which has been adjudicated bankrupt or a broker or dealer for which a YES NO
trustee has been appointed pursuant to the Securities Investor Protection Act of 1970 .....
(xii) Has been the subject of any order, judgment, decree or other sanction of a foreign court, foreign exchange,
or foreign government or regulatory agency arising out of any securities or investment advisory activities YES NO
...........................................................................................................................
(b) State whether applicant, or any person named in response to item 5 or 6, or any other person directly engaged
in the management, direction, supervision or performance or any of the applicant’s municipal securities dealer
activities, or who directly or indirectly controls any of such activities or who is directly or indirectly controlled YES NO
by applicant in connection with any of such activities, including any employee, is presently the subject of any
proceedings in which an adverse decision would result in any of the foregoing questions in part (a) being
answered “yes”..........................................................................................................................
If the answer to any paragraph of item 7 is “yes,” explain on Schedule A.
8.

Each jurisdiction with which applicant, or the bank of which applicant is a part, is licensed or registered as a
municipal securities dealer or to which application has been made should be listed in item 3. If any license or
registration listed therein is of a restricted nature or has been suspended or if any license or registration not listed
in item 3 was terminated, or withdrawn or voluntarily terminated, explain fully on Schedule C.

9.

Does applicant, or the bank of which applicant is a part, have any arrangement with any other person to perform YES NO
any services for applicant or for the bank relating to applicant’s municipal securities dealer activities? .............
If “yes,” explain on Schedule C hereto, identifying each such other person, the nature of applicant’s relation, if any,
to such persons, the nature of such services, and the arrangements pursuant to which such services are performed.
If any item on this page is amended, you must answer in full all other items on this page and file
with a completed page 1, and signed execution page. No Schedule required by any item on this page need be filed
with an amended item unless the Schedule itself is amended.
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FORM MSD Page 6
YES NO
10. (a) If applicant is a bank, does applicant maintain a municipal securities investment portfolio? .....................

(c) If applicant is a bank, does any person named in item 5 above or any person controlled by applicant in
connection with applicant’s municipal securities dealer activities, including any employee, engage in any YES NO
activities of the bank with respect to municipal securities other than municipal securities dealer activities?
If the answer to (c) is “yes” explain fully on Schedule C, setting forth the name of each such person, if such
person is named in item 5, or the function performed by each such person if not so named, and the nature of
each such person’s activities other than municipal securities dealer activities.
11. How many employees does applicant have engaged in its municipal securities dealer activities?
SUPERVISORY AND MANAGERIAL:
OTHER:

12. If applicant is a department or division of a bank:

[See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a)]

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS

(b) If applicant is a bank, does applicant buy and sell municipal securities in a fiduciary capacity or as agent for YES NO
customers? ..............................................................................................................................................

(a) Identify on Schedule C each geographic, organizational and operational unit of the bank of which applicant
is a part in which applicant’s municipal securities dealer activities are conducted, specifying the name and
location of each such unit and the nature of the municipal securities dealer activities conducted in each such
unit. Indicate on Schedule C whether any business activities other than municipal securities dealer activities
are conducted in any such unit, and describe the nature of such other activities.
(b) Does any unit of the bank of which applicant is a part, other than those identified in response to item 12(a), YES NO
perform any municipal securities dealer activities? ..................................................................................
If the answer to (b) is “yes,” explain on Schedule C hereto, identifying each such unit and the nature of the
activities performed by such unit.
(c) Are all records relating to applicant’s municipal securities dealer activities maintained separate and apart from YES NO
all other records of the applicant or of the bank of which applicant is a part? ...................................
(d) Are all records relating to applicant’s municipal securities dealer activities separately extractable from YES NO
applicant’s facilities or from the facilities of the bank of which applicant is a part? ..................................
Describe on Schedule C the manner in which all records relating to applicant’s municipal securities dealer
activities are maintained, including their location, how such records are collected and retrieved, the period of
time required to collect or retrieve any such record, the category of employees having authority to collect or
retrieve such records, and the name of each person who supervises the maintenance of such records.
(e) Are separate financial records maintained with respect to applicant’s municipal securities dealer activities? YES NO
If the answer to (e) is “yes,” explain on Schedule C the nature of such separate financial records.
(f) Does the bank of which applicant is a part maintain a municipal securities investment portfolio? ............

YES NO

(g) Does the bank of which applicant is a part buy and sell municipal securities in a fiduciary capacity or as agent YES NO
for customers? .........................................................................................................................................
(h) Does any person named in item 5 above or any person controlled by applicant in connection with applicant’s
municipal securities dealer activities, including any employee, engage in any activities of the bank with respect YES NO
to municipal securities other than municipal securities dealer activities? ......................................
If the answer to (h) is “yes,” explain fully on Schedule C, setting forth the name of each such person if such
person is named in item 5 or the function performed by each such person if not so named, and the nature of each
such person’s activities other than municipal securities dealer activities. If any of such other activities with
respect to municipal securities are performed by applicant, so specify on Schedule C.
If any item on this page is amended, you must answer in full all other items on this page and file
with a completed page 1, and signed execution page. No Schedule required by any item on this page
need be filed with an amended item unless the Schedule itself is amended.
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FORM MSD Execution Page

EXECUTION:

COUNTY OF _____________________________________

}

ss:

The undersigned, being first duly sworn, deposes and says that he or she has executed
this Form on behalf of, and with the authority of, the applicant named in item 2(a) and, if
applicant is a department or division of a bank, on behalf of, and with the authority of, the
bank named in item 2(d). The undersigned represents that the information and statements
contained herein, including exhibits attached hereto and other information filed herewith, all
of which are made a part hereof, are, to the best of the undersigned’s knowledge and belief
and on the basis of diligent inquiry, current, true, and complete. The undersigned further
represents that to the extent any information previously submitted is not amended, such
information is, to the best of the undersigned’s knowledge and belief and on the basis of
diligent inquiry, current, true, and complete.
[See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a)]

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS

STATE OF ________________________________________

Dated the ____________________________ day of __________________________ , 20 _____
________________________________________________________________________________
(Name of Applicant)

________________________________________________________________________________
(Manual signature of duly authorized officer)

________________________________________________________________________________
(Title)

Subscribed and sworn
to before me this
____________________________day of ____________________________ , 20____
_______________________________________________________________________
(Notary Public)

My commission expires:
____________________________________

10

OFFICIAL USE

Schedule A of FORM MSD
(Answers in response to items 5 and 7 of FORM MSD)
NOTE: (a) Complete a separate Schedule A for each person named in item 5 and each person subject to any action reported under
item 7.
(b) State all names in the order of last name, first name, full middle name. If any person legally has only an initial, so indicate
after the initial.
Full name of applicant exactly as stated in item 2(a) of Form MSD:

II. Full name of person for whom this Schedule is being completed:

III. (a) Residence address of person for whom this Schedule is being completed:

N UMBER

AND

S TREET

CITY

STATE

ZIP

CODE

(b) Date of Birth:

[See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a)]

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS

I.

(c) City of Birth:

(d) State or Province:

(e) Country:

IV. NAMES USED: Furnish below a list of all names individual has been known by or has used, including maiden name if applicable.
If no other names used, state “None.”
LAST

FIRST

MIDDLE

LAST

FIRST

MIDDLE

V. EDUCATION. Furnish below a description of the education of the person named in item II of this Schedule (include name and
location of last high school attended, name and location of any college or university attended, degree or degrees received and year
or years in which received).

VI. BUSINESS BACKGROUND: Furnish below a complete, consecutive statement of all business experience and employment
for the past ten years. List the last position first. If none, state “None.”
Name of Firm and Address

Kind of Business

Exact Nature of Connection
or Employment

Beginning Date
Mo.
Yrs.

Ending Date
Mo. Yrs.

VII.PROCEEDINGS: If any answer to any paragraph of item 7 is “Yes” with respect to the person for whom this Schedule is
being completed, furnish the following details:
Applicable
Paragraph
of Item 7

Title or Description
of Action

Name and Location of Court,
Agency, Jurisdiction or
Self-Regulatory Organization

Nature and Date
of Disposition of Proceeding

If any item on this page is amended, you must answer in full all other items on this page and file with a completed page 1,
and signed execution page. No Schedule required by an item on this page need be filed with an amended item unless
the Schedule itself is amended.
11

OFFICIAL USE

Schedule B of FORM MSD
(Answers in response to item 6 of FORM MSD)
I.

Full name of applicant exactly as stated in item 2(a) of Form MSD:

FULL NAME
Last
First
Middle
__________________
_________________________
_____________
____

BASIS FOR CONTROL
______________________________

[See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a)]

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS

II. Information with respect to persons described in item 6 of Form MSD:

If any item on this page is amended, you must answer in full all other items on this page and file with a completed
page 1, and signed execution page. No Schedule required by an item on this page need be filed with an amended
item unless the Schedule itself is amended.
12

OFFICIAL USE

Schedule C of FORM MSD

I.

Full name of applicant exactly as stated in item 2(a) of Form MSD:

II. Item of Form

ANSWER

[See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a)]

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS

(identify)

If any item on this page is amended, you must answer in full all other items on this page and file with a completed
page 1, and signed execution page. No Schedule required by an item on this page need be filed with an amended
item unless the Schedule itself is amended.
13