MSD-4 Uniform Application for Municipal Securities Principal o

Board of Governors of the Federal Reserve System OMB Number 7100-0100 Approval expires July 31, 2025

Federal Deposit Insurance Corporation

Office of the Comptroller of the Currency

OMB Number 3064-0022 Approval expires June 30, 2024

OMB Number 1557-0184 Approval expires August 31, 2025

Page 1 of 5

Board of Governors of the Federal Reserve System

Uniform Application for Municipal Securities Principal or

Municipal Securities Representative Associated with a

Bank Municipal Securities Dealer—Form MSD-4

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 OMB control number. The information provided by

each respondent is considered to be confidential.

06/2019

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 Office of Management and Budget, Washington, DC 20503, and, depending on your primary federal regulator, to Secretary, Board of Governors of the Federal Reserve System,

20th and C Streets, NW, Washington, DC 20551; or to Assistant Executive Secretary, Federal Deposit Insurance Corporation, Washington, DC 20429; or to Legislative and Regulatory

Activities Division, Office of the Comptroller of the Currency, Washington, DC 20219.

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. § 552a. 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.

Federal Deposit Insurance Corporation Privacy Act Notice

The Federal Deposit Insurance Corporation 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 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 representa-

tives, 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 qualification requirements. The informa-

tion you provide is protected by the Privacy Act, 5 U.S.C. § 552a. The information may be furnished to third parties as authorized by law and in accor-

dance with any of the other routine uses described in FDIC 30-64-0016, Professional Qualification Records for Municipal Securities Dealers, Municipal

Securities Representatives, and U.S. Government Securities Brokers/Dealers System of Records available at www.fdic.gov/about/privacy. 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.

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, and 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 profes-

sional qualification requirements. The information you provide is protected by the Privacy Act, 5 U.S.C. § 552a. 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 sys-

tem of record notice (Treasury/CC .210) available at https://www.federalregister.gov/documents/2016/01/19/2016-00763/privacy-act-of-1974-as-amend-

ed-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.

06/2019

Uniform Application for Municipal Securities Principal or

Municipal Securities Representative Associated with a

Bank Municipal Securities Dealer

Municipal Securities Representative

Municipal Securities Sales Limited Representative

Municipal Securities Principal

Government Securities Representative

Municipal Securities Fund Sales Limited Representative

Government Securities Supervisor

7.

Person Contacted

Employer

Name

Position

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.)

A.

Underwriting, trading or sales of municipal securities

B.

Financial advisory or consultant services for issuers in connection with issuance of municipal securities

C.

Research or investment advice with respect to municipal securities in connection with the activities

described in items 7.A and 7.B above

D.

Activities other than those specifically mentioned that involve communication directly or indirectly with public

investors in municipal securities in connection with the activities described in items 7.A and 7.B above

E.

Processing and clearing activities with respect to municipal securities

F.

Maintenance of records involving activities described in items 7.A through 7.E above

G.

Training of municipal securities principals or municipal securities representatives

City

State

Zip Code

Print Name of Municipal Securities Principal or Representative

Signature of Municipal Securities Principal or Representative

Date (MM/DD/YYYY)

Registration Number

B.

Main Street Address

Month/Day/Year

C.

Form MSD-4

Page 2 of 5

Last

First

Middle (if none, write “N/A”)

1.

Applicant Name:

2. Bank Municipal Securities Dealer:

5.

To be filed with the following (check one):

6.

Types(s) of Qualification Requested (check all that apply):

3.

Office of Employment Applicant:

4. Date of Employment with MSD:

It is anticipated that the applicant will perform the following functions in the capacity indicated (check all that apply):

8. For the purpose of verifying the information furnished on this application 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, and concerning the record and reputation of the applicant as related to the

ability to perform the duties for which employed or to be employed.

Name

A.

Name

Board of Governors of the Federal Reserve System

Federal Deposit Insurance Corporation

Comptroller of the Currency

CAPACITY

Supervisory

Non-

Supervisory

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Personal History of Applicant

9.

Name (Last, First, Middle)

10.

Not applicable.

Resident Street Address

11.

13.

Not applicable.

15.

Any other name ever used by which known:

Form MSD-4

Page 3 of 5

16.

EMPLOYMENT AND EDUCATION HISTORY. The following is a complete, consecutive statement of all my employment for the

past ten years starting with my immediately previous employer. (Include full- and part-time work, self employment, military service,

unemployment, and full-time education.) For each period of employment, list the position held at the time of leaving employment.

12.

City

State

Zip Code

14.

Not applicable.

17.

Address

From

(MM/YYYY)

To

(MM/YYYY)

Street

City/Town

State/Province

Zip/Postal Code

Country

Street

City/Town

State/Province

Zip/Postal Code

Country

Country

Street

City/Town

State/Province

Zip/Postal Code

City/Town

Street

State/Province

Zip/Postal Code

Country

RESIDENTIAL HISTORY.

The following is a complete, consecutive statement of all my residential addresses for the past five years starting with my current residence:

Type of

Business

From

(MM/YYYY)

To

(MM/YYYY)

Position

Held

Full-time or

Part-time

Reason for

Leaving

Name of Employer and

Complete Address

06/2019

19. Are you currently bonded? ...................................................................................................................................

Yes

No

If the answer to any of the following questions is Yes, attach complete details:

20.

Have you ever been refused coverage under a fidelity bond or has any surety company paid out any funds

on your coverage or cancelled such coverage? ...................................................................................................

Yes

No

21.

Have you ever been denied membership, registration, license, permit, or certification by any federal or state

securities or federal or state bank regulatory agency, any national securities exchange, registerd securities

association, or registered clearing agency? .........................................................................................................

Yes

No

Has any disciplinary action ever been taken against you, or any sanction imposed upon you, including any

finding that you were a cause of any disciplinary action or violated any law, rule or regulation or were an

aider, abettor, or co-conspirator in any such violation, by any federal or state securities or federal or state

bank regulatory agency, any national securities exchange, registered securities association, or registered

clearing agency? ..................................................................................................................................................

22.

Yes

No

While you were associated in any capacity with any broker, dealer or municipal securities dealer:

23.

A.

Was your registration denied, suspended or revoked?

...................................................................................

Yes

No

B.

Was your membership in any national securities exchange, registered securities association, or registered

clearing agency denied, suspended, or revoked, or was it expelled from any such organization? .................

Yes

No

24. Has any permanent or temporary injunction (including a cease and desist order) ever been entered against

you enjoining conduct as an investment advisor, underwriter, broker, dealer or municipal securities dealer

or as an affiliated person of any investment company, bank dealer, or municipal securities dealer or as an

affiliated person of any investment company, bank, insurance company, or enjoining any conduct related to

such activities or any transactions in any security? ..............................................................................................

Yes

No

25.

Have you been convicted within the past ten years of any felony or misdemeanor: (i) 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; (ii) arising out of the conduct of the business of a broker, dealer,

municipal securities dealer, investment adviser, bank, insurance company, or fiduciary; (iii) involving

larceny, theft, robbery, extortion, forgery, counterfeiting, fraudulent concealment, embezzlement, fraudulent

conversion, or misappropriation of funds or securities; (iv) involving crimes of concealment of assets, false

oaths or claims, bribery in a bankruptcy proceeding, mail fraud, fraud by wire (including telephone, telegraph,

radio, or television), fraud or false statements?...................................................................................................

Yes

No

representatives, or financial and operations principals prescribed by the Municipal Securities

Rulemaking Board? .........................................................................................................................................

Yes

No

If Yes, state below the type of examination and the approximate date taken.

Type of Examination

Approximate Date

(MM/YYYY)

Type of Examination

Approximate Date

(MM/YYYY)

B.

Have you ever been exempt from or received a waiver of the requirement to take and pass an

examination of the nature specified in Question 18.A? ..................................................................................

Yes

No

If Yes, state below the type of examination and the approximate date taken.

Type of Examination

Basis for Exemption or Waiver Approximate Date

(MM/YYYY)

Type of Examination

Basis for Exemption or Waiver Approximate Date

(MM/YYYY)

Signature of Municipal Securities Principal or Representative

Date (Month/Day/Year

Form MSD-4

Page 4 of 5

Personal History of Applicant—Continued

18. A.

Have you ever taken a qualification examination for municipal securities principals, municipal securities

06/2019

Acknowledgment for:

When the Form MSD-4 is received by the appropriate regulatory agency, this acknowledgment will be stamped to show

receipt and returned to the person named in item 29. The stamped acknowledgment should be retained to substantiate filing.

MAIL THE FORM TO THE REGULATOR INDICATED IN ITEM 5.

Board of Governors of the Federal Reserve System

Submit completed forms in Portable Document Format (PDF) to the Federal Reserve’s secure email address:

MSD-GSD-Registration@frb.gov

Federal Deposit Insurance Corporation

Submit completed forms in Portable Document Format (PDF) to the Federal Deposit Insurance Corporation’s secure email 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 MB-5100

Washington, DC 20429

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

Receipt Stamp

27.

Bank Municipal Securities Dealer Name

26.

Applicant Name

29.

Attention

Bank Municipal Securities Dealer Address

28.

City

State

Zip Code

Form MSD-4

Page 5 of 5

Form MSD-4

Form G-FIN-4

INSTRUCTIONS FOR PREPARATION OF

The Uniform Application for

Municipal Securities Representative

Associated with a Bank Municipal

Securities Dealer

Form MSD-4

General instructions

(1)

As used in these instructions and Form MSD-4:

a.

The term bank municipal securities dealer

means a municipal securities dealer that is a

bank or a department or division of a bank.

b.

The term applicant means a person who is, or

who seeks to be, associated with a bank

municipal securities dealer as a municipal

securities principal or municipal securities

representative.

(2)

Form MSD-4 is to be used by bank municipal

securities dealers and applicants to comply with

Municipal Securities Rulemaking Board Rule

G-7, “Information Concerning Associated Per-

sons,” which requires the filing of Form MSD-4.

(3)

Bank municipal securities dealers are required to

file Form MSD-4 with the appropriate regula-

tory agency as set forth below:

a.

A bank municipal securities dealer that is a

state member bank of the Federal Reserve

System, a department or division of any such

bank, a bank holding company (including a

subsidiary bank of the bank holding com-

pany if the subsidiary is not otherwise

instructed to file this form with the Federal

Deposit Insurance Corporation or the

Comptroller of the Currency in subpara-

graphs (b) or ( c) of this paragraph or with

the Securities and Exchange Commission,

and a division, department or subsidiary of

that subsidiary), a savings and loan holding

company, or a State branch or agency of a

foreign bank is required to file with the

Board of Governors of the Federal Reserve

System.

b.

A bank municipal securities dealer that is a

bank insured by the Federal Deposit Insur-

ance Corporation (other than a bank which

is a member of the Federal Reserve System)

or a department or division of any such

bank, is required to file with the Federal

Deposit Insurance Corporation.

c.

A bank municipal securities dealer that is a

national bank or bank operating under the

Code of Law for the District of Columbia,

or a department or division of any such

bank, is required to file with the Comptroller

of the Currency.

(4)

Copies of Form MSD-4 may be obtained from

the appropriate regulatory agency listed in

instruction 3.

(5)

Bank municipal securities dealers that file with

the Federal Deposit Insurance Corporation may

either mail an original and one copy of Form

MSD-4 and any attachments within ten days of

association with the municipal securities dealer

or, alternatively, submit an electronic copy of the

form (available at www.fdic.gov), and attach-

ments, in Portable Document Format (“PDF”)

to the secure email address

MSD-GSD-

Registration@FDIC.gov within ten days of

association with the municipal securities dealer.

Bank municipal securities dealers that file with

the Comptroller of the Currency must submit

an electronic copy of the form and attachments

to the OCC’s BankNet website at www.banknet-

.gov within ten days of association with the

municipal securities dealer. A bank municipal

securities dealer filing Form MSD-4 shall retain

an exact copy in its records for at least three

years after the applicant’s employment or other

association with such dealer has terminated.

GEN-1

Form MSD-4

March 2017

(6)

A bank municipal securities dealer required to

file with the Board of Governors of the Federal

Reserve System must submit an electronic copy

of the form and attachments to the secure email

address MSD-GSD-Registration@FRB.gov.

Report the form and attachments in Por-

table Document Format (“PDF”). Form

MSD-4 must be submitted within ten days of

association with the municipal securities dealer.

A bank municipal securities dealer filing Form

MSD-4 shall retain an exact copy in its records

for at least three years after the applicant’s

employment or other association with such

dealer has terminated.

(7)

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 shall be typed on white 8-1/2 x 11

in. paper.

(8)

Form MSD-4 and any attachments may be

duplicated by any method which produces leg-

ible copies of type size identical to that of the

Form MSD-4 on white 8-1/2 x 11 in. paper.

(9)

Form MSD-4 shall be manually signed on page

1 (bottom) by a municipal securities principal of

the employing bank municipal securities dealer

and on page 3 by the applicant.

(10)

All items on Form MSD-4 must be completed.

The date on which the Form MSD-4 is received

by the appropriate regulatory agency shall be the

date of filing. A Form MSD-4 which is not pre-

pared and executed in accordance with the

applicable requirements may be returned as

unacceptable. Acceptance for filing shall not

constitute any finding that a Form MSD-4 has

been completed in accordance with those

requirements or that any information reported

on the form is true, current, complete, or not

misleading.

(11)

Section 17(c)(1) of the Securities Exchange Act

of 1934 requires every bank municipal securities

dealer that files any application, notice, report,

or document with its appropriate regulatory

agency to file a copy of that application, notice,

report, or document with the Securities and

Exchange Commission (SEC). The SEC and the

appropriate regulatory agencies listed in instruc-

tion 3 have developed procedures under which

the latter will send a copy of any application,

notice, report, or document filed with them by a

bank municipal securities dealer to the SEC.

Accordingly, when this form is filed with the

appropriate regulatory agency, it will be deemed

to have been filed with the SEC.

Instructions To Specific Items on

Form MSD-4

(12)

Items 2 through 8 are to be completed by the

bank municipal securities dealer employing or

proposing to employ the applicant named in

item 1. All other items are to be completed by

the applicant.

(13)

Item 3: Give the address of the office of the

bank municipal securities dealer in which the

applicant is or will be employed.

(14)

Item 5: Indicate the appropriate regulatory

agency as set forth in General Instruction 3.

(15)

Item 6: Municipal Securities Rulemaking Board

Rule G-3, “Classification of Principals and Rep-

resentatives; Numerical Requirements; Testing,”

provides a description of the functions per-

formed by a municipal securities principal or

municipal securities representative. NOTE: If

this form is being filed in lieu of Form G-FIN-4,

check all applicable types of qualifications

requested in item 6.

(16)

Item 16: Account for all time periods.

(17)

Item 25:

a.

Although this item relates only to convic-

tions during the past ten years, it should be

noted that section 19 of the Federal Deposit

Insurance Act (12 U.S.C. section 1829) pro-

hibits any insured bank, except with the writ-

ten consent of the Federal Deposit Insurance

Corporation, from employing any person

who has ever been convicted of a criminal

Form MSD-4

GEN-2

March 2017

Form MSD-4

offense involving dishonesty or breach of

trust;

b.

Paragraph (iv) of this item relates only to

convictions within the past ten years under

sections 152, 1341, 1342, 1343, or Chapters

25 or 47 of Title 18, United States Code.

Form MSD-4

GEN-3

Form MSD-4

March 2019