Form SEC 2901 SEC 2901 Form MA-W

FORM MA-W

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3235-0681
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NOTICE OF WITHDRAWAL FROM REGISTRATION AS A MUNICIPAL ADVISOR
Please refer to the General Instructions for forms in the MA series before completing this form. All italicized terms
herein are defined or described in the Glossary of Terms appended to the General Instructions.
A municipal advisor must complete this Form MA-W to withdraw its municipal advisor registration with the SEC.
WARNING:

Complete this form truthfully. False statements or omissions may result in administrative or civil
action or criminal prosecution.

Item 1 Identifying Information
A. Full Legal Name:
The name entered here must be the same as the name entered on the registrant’s most recent Form MA. Do
not report a name change on this Form MA-W.
______________________________________________________________________________
B. SEC File Number: ______________

Item 2 Contact Person (for Municipal Advisory Firms)
The registrant’s contact person must be a principal or employee (not outside counsel) of the municipal advisor
authorized to receive information and respond to questions about this Form MA-W.
Name, title, and contact information:
________________________________________________________________
(name)
(title)
________________________________________________________________
(number and street)
________________________________________________________________
(city)
(state)
(country)
(postal code)
___________________________________
(area code) (telephone number)
_____________________________@______________
(E-mail address)

Item 3 Money Owed to Clients
Has the registrant:
A. Received any pre-paid municipal advisory fees for municipal advisory activities, including subscription fees
for publications, that have not been delivered?
Yes
No

If “yes,” what is the amount owed for these pre-paid services (including subscriptions)?
B. Borrowed any money from clients that has not been repaid?
If “yes,” what is the amount owed for these borrowed funds?

SEC 2901 (4/14)

$_______.00
Yes

No

$_______.00

Item 4 Advisory Contract Assignments
Has the registrant assigned any municipal advisory contracts to another person that engages in municipal
advisory activities?
Yes
No
If yes, list on Section 4 of Schedule W1 each person to whom the registrant has assigned any such municipal
advisory contracts and provide the requested information.

Item 5 Judgments and Liens
Are there any unsatisfied judgments or liens against the registrant?

Yes

No

Item 6 Books and Records
NOTE: Rule 15Ba1-8 under the Exchange Act requires a municipal advisor to preserve its books and records
after the municipal advisor ceases to conduct or discontinues business as a municipal advisor.
Provide in Schedule W1 the name and address of each person who has or will have custody or possession of
the municipal advisor’s books and records and each location at which any of such books and records are or will
be kept.

Item 7 Statement of Financial Condition
If registrant answered “yes” to Item 3A, Item 3B, or Item 5, complete Schedule W2, disclosing the nature and
amount of the registrant’s assets and liabilities and net worth as of the last day of the month prior to the filing
of this Form MA-W.

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Execution
For a Sole Proprietor:
I, the undersigned, certify, under penalty of perjury under the laws of the United States of America, that the information
and statements made in this Form MA-W, including exhibits and any other information submitted, are true. I further
certify that the books and records of my municipal advisor-related business will be preserved and available for
inspection as required by law, and that all information submitted on my most recent Form MA and Form MA-I is
accurate and complete as of this date. I understand that if any information contained in this Form MA-W is different
from the information contained on my Form MA and Form MA-I, the information on this Form MA-W will replace the
corresponding entry on my Form MA and Form MA-I. Finally, I authorize any person having custody or possession of
these books and records to make them available to authorized regulatory representatives.
Signature:
Printed Name:

_________________________________
_________________________________

Date:
Title:

__________________________
__________________________

For a Municipal Advisory Firm:
I, the undersigned, have signed this Form MA-W on behalf of, and with the authority of, the municipal advisor
withdrawing its registration. The advisor and I both certify, under penalty of perjury under the laws of the United States
of America, that the information and statements made in this Form MA-W, including exhibits and any other information
submitted, are true. I further certify that the municipal advisor’s books and records will be preserved and available for
inspection as required by law, and that all information submitted on the municipal advisor’s most recent Form MA is
accurate and complete as of this date. The municipal advisor and I understand that if any information contained in this
Form MA-W is different from the information contained on Form MA, the information on this Form MA-W will
replace the corresponding entry on the municipal advisor’s Form MA. Finally, I authorize any person having custody
or possession of these books and records to make them available to authorized regulatory representatives.
Signature:
Printed Name:

_________________________________
_________________________________

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Date:
Title:

__________________________
__________________________

FORM MA-W Schedule W1
Certain items in Form MA-W may require additional information on this Schedule W1. Use this Schedule W1 to report details for
items listed below. Report only new information or changes/updates to previously submitted information. Do not repeat previously
submitted information.
SECTION 4

Advisory Contract Assignments

Check here if this section is being completed:
Complete the following information for each person to whom the registrant has assigned any advisory contract to provide municipal
advisor-related services. Complete a separate Schedule W1 for each person to whom the registrant has assigned such a contract.
Name and business address of the person to whom advisory contracts were assigned:
_____________________________________________________________________________________________________
(name)
_____________________________________________________________________________________________________
(number and street)
_____________________________________________________________________________________________________
(city)
(state)
(country)
(postal code)
______________________________________
(area code)
(telephone number)

Is this address a private residence?
SECTION 6

Yes

No

Books and Records

Person with Custody
Complete the following information for the person that has or will have custody or possession of the books and records kept at the
location described in this Section 6 of this Schedule. A separate Schedule W1 must be completed for each person that has or will
have custody of any of the registrant’s books and records. If the person listed below has or will have custody of any of the
registrant’s books and records at any other location, a separate Schedule W1 must be completed listing this person and each other
location where the person has custody of the registrant’s books and records.
_____________________________________________________________________________________________________
(name)
_____________________________________________________________________________________________________
(number and street)
_____________________________________________________________________________________________________
(city)
(state)
(country)
(postal code)
______________________________________
(area code)
(telephone number)

Is this address a private residence?

Yes

No

Location
Complete the following information for the location where the books and records of which the person listed in this Section 6 of this
Schedule has or will have custody or possession. A separate Schedule W1 must be completed for each location at which the
registrant’s records are or will be kept. If any other person has or will have custody or possession of any of the books and records at
the location described below, a separate Schedule W1 must be completed listing this location and each other person that has or will
have custody of the registrant’s books and records.
_____________________________________________________________________________________________________
(name)
_____________________________________________________________________________________________________
(number and street)
_____________________________________________________________________________________________________
(city)
(state)
(country)
(postal code)
______________________________________
(area code)
(telephone number)

Is this address a private residence?
Yes
No
Briefly describe the books and records kept at this location.

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___________________________________________

FORM MA-W Schedule W2
If the registrant answered “yes” to Item 3A, 3B, or 5 of Form MA-W, complete this Schedule W2. This balance sheet must be
prepared in accordance with generally accepted accounting principles, but need not be audited.
SECTION 7

I.

STATEMENT OF FINANCIAL CONDITION

Assets

Current Assets
Cash
Securities at Market
Non-Marketable Securities
Other Current Assets
Total Current Assets

___________________________
___________________________
___________________________
___________________________
$ __________________________

Fixed Assets
Total Fixed Assets

$ __________________________

TOTAL ASSETS

$

II.

Liabilities & Shareholders’ Equity

Current Liabilities
Prepaid Advisory Fees
Short-Term Loans from Clients
Other Short-Term Loans
Other Current Liabilities
Total Current Liabilities

___________________________
___________________________
___________________________
___________________________
$ __________________________

Fixed Liabilities
Long-Term Debt Owed to Clients
Other Long-Term Debt
Other Long-Term Liabilities
Total Fixed Liabilities

___________________________
___________________________
___________________________
$ __________________________

Shareholders’ Equity
Total Shareholders’ Equity (or Deficit)

$ __________________________

TOTAL LIABILITIES AND SHAREHOLDERS’ EQUITY

$

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