6200-55 Form MSD-5 Uniform Termination Notice for Municipal Prin

FDIC OMB No. 3064-0022; Expiration Date: 06/30/2024
FRB OMB No. 7100-0100; Expiration Date: 07/31/2022
OCC OMB No. 1557-0184; Expiration Date: 09/30/2022

Federal Deposit Insurance Corporation

FORM MSD-5
UNIFORM TERMINATION NOTICE FOR MUNICIPAL SECURITIES PRINCIPAL OR
MUNICIPAL SECURITIES REPRESENTATIVE ASSOCIATED WITH A BANK
MUNICIPAL SECURITIES DEALER
The Board of Governors of the Federal Reserve System, the Federal Deposit Insurance Corporation, and the Office of the Comptroller of the Currency
are authorized to collect this information pursuant to the authority contained in the following statutes: 15 U.S.C. §§
78o-4, 78q, and 78w.
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 Office
of Management and Budget (OMB) control number. The information provided by each respondent is considered to be confidential.

FEDERAL DEPOSIT INSURANCE CORPORATION PRIVACY ACT NOTICE
The FDIC is authorized to request this information from you by Sections 15B(c), 15C, 17 and 23 of the Securities Exchange Act of 1934 (15 U.S.C.
78o-4, 78o-5, and 78q and 78w); and Section 9 of the Federal Deposit Insurance Act (12 U.S.C. 1819). The purpose for collecting the information is to
comply with the registration requirements of municipal securities dealers, municipal securities representatives, and U.S. Government securities brokers
or dealers and associated persons contained in the Securities Exchange Act of 1934, and to support the FDIC's regulatory and supervisory functions.
Furnishing the requested information is mandatory. Failure to provide the requested information in whole or in part may delay or prohibit the
determination of your compliance with applicable registration and professional qualifications requirements. The information you provide is protected by
the Privacy Act, 5 USC 552(a). The information may be furnished to third parties as authorized by law and used according to any of the routine uses
described in the Professional Qualification Records for Municipal Securities Dealers, Municipal Securities Representatives, and U.S. Government
Securities Brokers/Dealers System of Records (30-64-0016) available at www.fdic.gov/about/privacy/index.html. If you have questions or concerns
about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at Privacy@fdic.gov.

BOARD OF GOVERNORS OF THE FEDERAL RESERVE SYSTEM PRIVACY ACT NOTICE
The Federal Reserve Board is authorized to request this information from you by Sections 3, 15B(c), 15C, 17 and 23 of the Securities Exchange Act of
1934 (15 U.S.C. 78c, 78o-4, 78o-5, and 78q and 78w); and Section 11 of the Federal Reserve Act (12 U.S.C. 248). The purpose for collecting the
information is to comply with the registration requirements of municipal securities dealers, municipal securities representatives, and U.S. Government
securities brokers or dealers and associated persons contained in the Securities Exchange Act of 1934, and to support the Board's regulatory and
supervisory functions. Furnishing the requested information is mandatory. Failure to provide the requested information in whole or in part may delay or
prohibit the determination of your compliance with applicable registration and professional qualification requirements. The information you provide is
protected by the Privacy Act, 5 U.S.C. 552(a). The information may be furnished to third parties as authorized by law and used according to any of the
routine uses as described in the system of Records entitled BGFRS-17” FRB --Municipal or Government Securities Principals or Representatives,”
available at https://www.federalreserve.gov/files/BGFRS-17-municipal-or-government-securities-principals-and-representatives.pdf. If you have any
questions or concerns about the collection or use of the information, you may contact the Secretary of the Board, Board of Governors of the Federal
Reserve System, 20th Street and Constitution Avenue, NW, Washington, DC 20551.

OFFICE OF THE COMPTROLLER OF THE CURRENCY PRIVACY ACT NOTICE
The Office of the Comptroller of the Currency is authorized to request this information from you by 12 U.S.C. 1, 481, 1464, 1818, and 1820; 15 U.S.C.
78o-4, 78o-5, 78q, and 78w. The purpose of collecting the information is for the OCC to carry out its responsibilities under the federal securities laws
relating to the professional qualifications and fitness of individuals who engage or propose to engage in securities activities on behalf of national banks,
federal savings associations, and District of Columbia savings associations operating under the OCC's regulatory authority. Failure to provide the
requested information in whole or in part may delay or prevent the determination of your compliance with applicable registration and professional
qualification requirements. The information you provide is protected by the Privacy Act, 5 U.S.C. 552(a). The information may be furnished to third
parties as authorized by law and used according to any of the routine uses described in the Bank Securities Dealers System --Treasury/Comptroller
system of record notice (Treasury/CC .210) available at https://www.federalregister.gov/documents/2016/01/19/2016-00763/privacy-act-of-1974-asamended-system-of-records. If you have any questions or concerns about the collection or use of the information, you may contact the Deputy
Comptroller, Market Risk Division, Office of the Comptroller of the Currency, 400 Seventh St S.W., Suite 7W-215, Washington D.C. 20219.
PAPERWORK REDUCTION ACT NOTICE
Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time to gather and maintain data in
the required form and to review instructions and to complete the information collection. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to the Paperwork Reduction Act Clearance Officer, Legal
Division, Federal Deposit Insurance Corporation, 550 17th Street, N.W., Washington, D.C. 20429, and the Office of Management and Budget,
Paperwork Reduction Project (3064-0022) Washington, DC 20503.
Page down to access form FDIC 6200/55

FDIC 6200/55 (6-21)

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FDIC OMB No. 3064-0022; Expiration Date: 06/30/2024
FRB OMB No. 7100-0100; Expiration Date: 07/31/2022
OCC OMB No. 1557-0184; Expiration Date: 09/30/2022

Federal Deposit Insurance Corporation

FORM MSD-5
UNIFORM TERMINATION NOTICE FOR MUNICIPAL SECURITIES PRINCIPAL OR
MUNICIPAL SECURITIES REPRESENTATIVE ASSOCIATED WITH A BANK
MUNICIPAL SECURITIES DEALER
INSTRUCTIONS: For complete instructions, see form FDIC 6200/55i, Instructions for MSD-5 Uniform Termination Notice for Municipal Securities
Principal or Municipal Securities Representative Associated with a Bank Municipal Securities Dealer. This form may be completed electronically and
submitted to the Federal Deposit Insurance Corporation using the Submit button above to the right. By selecting the Submit button, the form will be
emailed to MSD-GSD-Registration@fdic.gov for processing. If you wish to print the form to mail your submission, select the Set Form to Print button
above to the left and all hidden fields will be expanded. Once printed and completed, the form should be mail to the Federal Deposit Insurance
Corporation, Division of Consumer Protection, Policy and Program Development Section, Room F-6044, 550 17th Street, NW, Washington, DC
20429.
NOTE: Must have Adobe Pro DC or Adobe Pro to attach files.
SECTION I - GENERAL INFORMATION
1. Name (Last, First, MI)

2. Social Security Number (Optional)

Municipal Securities

3. Capacity (Select all that apply):

Government Securities

4. Bank Municipal Securities Dealer
a. Name

b. Registration Number

c. Address (Street, City, State, and ZIP Code)

5. To be filed with:

Federal Deposit Insurance Corporation

Board of Governors of the Federal Reserve

Comptroller of the Currency

SECTION II - EMPLOYMENT STATUS
7. Date Termminated

6. Office of Employment Address (Street, City, State, ZIP Code)

8. Reason for Termination
Resigned

Deceased

Discharged

Other

9. While associated with the dealer named in item 4, was the individual named in item 1 the subject of any investigation, proceeding, disqualification,
or disciplinary action by any government agency or self-regulatory organization (as defined in section 3(a)(26) of the Securities Exchange Act of
1934) described in Rules G-4 and G-5 of the Municipal Securities Rulemaking Board?
Yes
No
SECTION III - MUNICIPAL SECURITIES PRINCIPAL SIGNATURE
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. sections 1001 and 1005, and 15 U.S.C. 78ff.)
10. Name

12. Date

11. Signature

13. Person To Contact For Further Information
a. Name

b. Telephone

c. Address (Street, City, State, and ZIP Code)

SECTION IV - ACKNOWLEDGMENT
14. Acknowledgment for:

Form MSD-5

Form G-FIN-5

15. Name of Person Terminated (Last, First, MI):
16. Bank Municipal Securities Dealer Name:

Receipt Stamp

17. Bank Municipal Securities Dealer Address:
18. Attention:
FDIC 6200/55 (6-21)

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FDIC OMB No. 3064-0022; Expiration Date: 06/30/2024
FRB OMB No. 7100-0100; Expiration Date: 07/31/2022
OCC OMB No. 1557-0184; Expiration Date: 09/30/2022
WHEN THE FORM MSD-5 IS RECEIVED BY THE APPROPRIATE REGULATORY AGENCY, THIS ACKNOWLEDGMENT
WILL BE STAMPED TO SHOW RECEIPT AND RETURNED TO THE PERSON NAMED IN ITEM 18. THE STAMPED
ACKNOWLEDGMENT SHOULD BE RETAINED TO SUBSTANTIATE FILING.

Print to Submit Form

MAIL THE FORM TO THE REGULATOR INDICATED IN ITEM 5.

Federal Deposit Insurance Corporation
Submit completed forms in Portable Document Format (PDF) to the Federal Deposit Insurance Corporation's secure e-mail address:
MSD-GSD-Registration@fdic.gov or alternatively, mail the form and any attachments to:
Federal Deposit Insurance Corporation
Policy & Program Development Section
550 17th Street, NW, Room F-6044
Washington, D.C. 20429
Board of Governors of the Federal Reserve System
Submit completed forms in Portable Document Format (PDF) to the Federal Reserve's secure e-mail address: MSD-GSD-Registration@frb.gov
The Office of the Comptroller of the Currency
Upload completed forms via the OCC's BankNet website www.banknet.gov
For assistance call (202) 649-6438

FDIC 6200/55 (6-21)

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