MSD-5 Uniform Termination Notice for Municipal Securities Prin

Board of Governors of the Federal Reserve System OMB Number 7100-0101 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 3

Board of Governors of the Federal Reserve System

Federal Deposit Insurance Corporation

Office of the Comptroller of the Currency

Uniform Termination Notice for Municipal Securities Principal or

Municipal Securities Representative Associated with a

Bank Municipal Securities Dealer—Form MSD-5

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 15 minutes 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 professional qual-

ification 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 system of

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

tem-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

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.)

Print Name of Municipal Securities Principal

Signature of Municipal Securities Principal

Date (MM/DD/YYYY)

Form MSD-5

Page 2 of 3

Last

First

Middle (if none, enter “N/A”)

7.

Reason for Termination (check one):

8.

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?

2.

Capacity (check all that apply):

Municipal Securities

Government Securities

Resigned*

Discharged*

Deceased

Other*

*Furnish full details on attached sheet if related to a violation or probable violation of banking or securities law.

Yes**

No

**Furnish full details on attached sheet.

9. To be filed with the following (check one):

Board of Governors of the Federal Reserve System

Federal Deposit Insurance Corporation

Comptroller of the Currency

Person to contact for further information:

Name

Street Address

City

State

Zip Code

Area Code / Phone Number

Main Street Address

City

State

Zip Code

Registration Number

B.

C.

3. Bank Municipal Securities Dealer:

4.

Office of Employment Address:

5.

Date Terminated:

Name

A.

Street Address

City

State

Zip Code

Month/Day/Year

Uniform Termination Notice for Municipal Securities Principal

or Municipal Securities Representative Associated with a

Bank Municipal Securities Dealer

1.

Individual’s Name:

06/2019

Acknowledgment for:

Form MSD-5

Form G-FIN-5

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 13. The stamped acknowledgment should be retained to substantiate filing.

Form MSD-5

Page 3 of 3

Receipt Stamp

11.

Bank Municipal Securities Dealer Name

10.

Name of Person Terminated

13.

Attention

Bank Municipal Securities Dealer Address

12.

City

State

Zip Code

MAIL THE FORM TO THE REGULATOR INDICATED IN ITEM 9.

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 Corporations’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 MB-5100

Washington, D.C. 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

INSTRUCTIONS FOR PREPARATION OF

The Uniform Termination Notice for

Municipal Securities Principal or

Municipal Securities Representative

Associated with a Bank Municipal

Securities Dealer

Form MSD-5

General instructions

(1)

As used in these instructions and Form MSD-5,

the term bank municipal securities dealer means

a municipal securities dealer that is a bank or a

department or division of a bank.

(2)

Form MSD-5 is intended for use by bank

municipal securities dealers in reporting the ter-

mination of a municipal securities principal’s or

municipal securities representative’s association

with such dealer.

(3)

Bank municipal securities dealers are required to

file Form MSD-5 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 Federal

Reserve System member bank) or a depart-

ment 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-5 may be obtained from

any one of the regulatory agencies 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-5 and any attachments within thirty days

after termination of the association with the

individual named in item 1 or, alternatively, sub-

mit an electronic copy of the form (available at

www.fdic.gov) and attachments, in Por-

table Document Format (“PDF”) to the secure

email address

MSD-GSD-

Registration@FDIC.gov within thirty days after

termination of association with the individual

named in item 1. Bank municipal securities deal-

ers that file with the Comptroller of the Cur-

rency must submit an electronic copy of the

form and attachments to the OCC’s BankNet

website at www.banknet.gov within thirty days

after termination of the association with the

individual named in item 1. A bank municipal

securities dealer filing Form MSD-5 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.

(6)

A bank municipal securities dealer required to

file with the Board of Governors of the Federal

Reserve System must submit an electronic copy

GEN-1

Form MSD-5

March 2017

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-5 must be submitted within thirty days

after termination of the association with the

individual named in item 1. A bank municipal

securities dealer filing Form MSD-5 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 should be typed on white 8-1/2 x 11

in. paper. The answers to more than one ques-

tion may appear on an attachment sheet if the

questions are clearly identified. Attachments

should be paginated and the name of both the

person terminated and the bank municipal secu-

rities dealer should appear on every attachment

sheet.

(8)

Form MSD-5 and any attachments may be

duplicated by any method which produces leg-

ible copies of type size identical to that of the

Form MSD-5 on white 8-1/2 x11 in. paper.

(9)

Form MSD-5 shall be manually signed on page

1 (bottom) by a municipal securities principal of

the employing bank municipal securities dealer.

(10)

All items on Form MSD-5 must be completed.

The date on which Form MSD-5 is received by

the appropriate regulatory agency shall be the

date of filing. A Form MSD-5 that 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-5 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 transmit a copy of any applica-

tion, 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.

(12)

If this form is being filed in lieu of Form

G-FIN-5, check all applicable types of

qualifications requested in item 2.

Form MSD-5

GEN-2

March 2019

Form MSD-5