Copy to Jack Habert, 12/28/201 

 

 

Form SBSE-A OMB Approval 

OMB Number: 3235-0696

Expires: April 30, 2022

Estimated average burden hours per 

response: 34 hours 

per amendment: 1 hour 

Application for Registration 

of Security-based Swap 

Dealers and Major Securitybased Swap Participants that 

are Registered or Registering 

with the Commodity Futures 

Trading Commission as a 

Swap Dealer or Major Swap 

Participant 

Persons who 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. 

SEC 2925 (9/19)
Copy to Jack Habert, 12/28/201 

 

 

 

 

 

FORM SBSE-A INSTRUCTIONS 

A. GENERAL INSTRUCTIONS

1. FORM - Form SBSE-A is the Application for Registration as either a Security-based Swap Dealer or Major

Security-based Swap Participant (collectively, “SBS Entities”) by an entity that is not registered or registering with

the Commission as a broker-dealer but is registered or registering with the Commodity Futures Trading

Commission (“CFTC”) as a swap dealer or major swap participant. These SBS Entities must file this form and

a legible copy of the Form 7-R they file with the CFTC (or its designee) to register with the Securities and

Exchange Commission. An applicant must also file Schedules A, B, D and F, as appropriate. There is no

Schedule E. An entity that is registered or registering with the Commission as a broker-dealer and also is

registered or registering with the Commodity Futures Trading Commission (“CFTC”) as a swap dealer or major

swap participant should file Form SBSE-BD to register with the Commission as an SBS Entity.

2. ELECTRONIC FILING - This Form SBSE-A must be filed electronically with the Commission through the EDGAR

system, and must utilize the EDGAR Filer Manual (as defined in 17 CFR 232. 11) to file and amend Form SBSEA electronically to assure the timely acceptance and processing of those filings. Additional documents shall be

attached to this electronic application.

3. UPDATING - By law, the applicant must promptly update Form SBSE-A information by submitting amendments

whenever the information on file becomes inaccurate or incomplete for any reason [17 CFR 240.15Fb2-3]. In

addition, the applicant must update any incomplete or inaccurate information contained on Form SBSE-A prior to

filing a notice of withdrawal from registration on Form SBSE-W [17 CFR 15Fb3-2(a)].

4. CONTACT EMPLOYEE - The individual listed as the contact employee must be authorized to receive all

compliance information, communications, and mailings, and be responsible for disseminating it within the

applicant's organization.

4. FEDERAL INFORMATION LAW AND REQUIREMENTS - 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 control number.

Sections 15F, 17(a) and 23(a) of the Exchange Act authorize the SEC to collect the information on this form from

registrants. See 15 U.S.C. §§78o-10, 78q and 78w. Filing of this form is mandatory. The principal purpose of this

Form is to permit the Commission to determine whether the applicant meets the statutory requirement to engage

in the security-based swap business. The Commission maintains a file of the information on this form and will

make information collected via the form publicly available. Any member of the public may direct to the

Commission any comments concerning the accuracy of the burden estimate on this Form, and any suggestions

for reducing this burden. This collection of information has been reviewed by the Office of Management and

Budget in accordance with the clearance requirements of 44 U.S.C. §3507. The information contained in this

form is part of a system of records subject to the Privacy Act of 1974, as amended. The Securities and Exchange

Commission has published in the Federal Register the Privacy Act Systems of Records Notice for these records.

B. FILING INSTRUCTIONS

1. FORMAT

a. Items 1-19 and the accompanying Schedules and DRP pages must be answered and all fields requiring a

response must be completed before the filing will be accepted.

b. Failure to follow instructions or properly complete the form may result in the application being delayed or

rejected.

c. Applicant must complete the execution screen certifying that Form SBSE-A and amendments thereto

have been executed properly and that the information contained therein is accurate and complete.

d. To amend information, the applicant must update the appropriate Form SBSE-A screens.

e. A paper copy, with original signatures, of the initial Form SBSE-A filing and amendments to Disclosure

Reporting Pages (DRPs) must be retained by the applicant and be made available for inspection upon a

regulatory request.

2. DISCLOSURE REPORTING PAGE (DRP) – Information concerning a principal that relates to the occurrence

of an event reportable in Schedule D must be provided on the appropriate DRP.

The mailing address for questions and correspondence is: 

The Securities and Exchange Commission
 

Washington, DC 20549
 
Copy to Jack Habert, 12/28/2011 

 

 

EXPLANATION OF TERMS 

(The following terms are italicized throughout this form.)
 

1. GENERAL 

Terms used in this Form SBSE-A that are defined in the form the CFTC requires that swap dealers and major swap 

participants use to apply for registration with the CFTC shall have the same meaning as set forth in that form. 

APPLICANT - The security-based swap dealer or major security-based swap participant applying on or amending this 

form. 

CONTROL - The power, directly or indirectly, to direct the management or policies of a company, whether through 

ownership of securities, by contract, or otherwise. Any person that (i) is a director, general partner or officer exercising 

executive responsibility (or having similar status or functions); (ii) directly or indirectly has the right to vote 25% or 

more of a class of a voting security or has the power to sell or direct the sale of 25% or more of a class of voting 

securities; or (iii) in the case of a partnership, has the right to receive upon dissolution, or has contributed, 25% or 

more of the capital, is presumed to control that company. 

JURISDICTION - A state, the District of Columbia, the Commonwealth of Puerto Rico, the U.S. Virgin Islands, or any 

subdivision or regulatory body thereof. 

SUCCESSOR –The term “successor” is defined to be an unregistered entity that assumes or acquires substantially all 

of the assets and liabilities, and that continues the business of, a predecessor security-based swap dealer or major 

security-based swap participants that ceases its security-based swap activities. [See Exchange Act Rule 15b2-5 (17 

CFR 240.15Fb2-5)] 

UNIQUE IDENTIFICATION CODE or UIC – For purposes of Form SBSE-A, the term “unique identification code” or 

“UIC” means a unique identification code assigned to a person by an internationally recognized standards-setting 

system that is recognized by the Commission [pursuant to Rule 903(a) of Regulation SBSR (17 CFR 242.903(a))]. 

3. FOR THE PURPOSE OF SCHEDULE D AND THE CORRESPONDING DISCLOSURE REPORTING PAGES 

(DRPs) 

FOREIGN FINANCIAL REGULATORY AUTHORITY - Includes (1) a foreign securities authority; (2) other 

governmental body or foreign equivalent of a self-regulatory organization empowered by a foreign government to 

administer or enforce its laws relating to the regulation of financial services industry-related activities; and (3) a foreign 

membership organization, a function of which is to regulate the participation of its members in the activities listed 

above. 

FINANCIAL SERVICES INDUSTRY-RELATED – Pertaining to securities, commodities, banking, savings association 

activities, credit union activities, insurance, or real estate (including, but not limited to, acting as or being associated 

with a broker-dealer, municipal securities dealer, government securities broker or dealer, issuer, investment company, 

investment adviser, futures sponsor, bank, security-based swap dealer, major security-based swap participant, 

savings association, credit union, insurance company, or insurance agency). (This definition is used solely for the 

purpose of Form SBSE-A.) 

INVOLVED - Doing an act or aiding, abetting, counseling, commanding, inducing, conspiring with or failing reasonably 

to supervise another in doing an act. 

ORDER - A written directive issued pursuant to statutory authority and procedures, including orders of denial, 

suspension, or revocation; does not include special stipulations, undertakings or agreements relating to payments, 

limitations on activity or other restrictions unless they are included in an order. 

PROCEEDING - Includes a formal administrative or civil action initiated by a governmental agency, self-regulatory 

organization or a foreign financial regulatory authority; a felony criminal indictment or information (or equivalent formal 

charge); or a misdemeanor criminal information (or equivalent formal charge). Does not include other civil litigation, 

investigations, or arrests or similar charges effected in the absence of a formal criminal indictment or information (or 

equivalent formal charge). 
Copy to Jack Habert, 12/28/201 

 

 

 

 

 

 

City: State: Country: Zip/Postal Code: 

 

 

 

 

 

 

Official Use Official 

Use 

Only 

INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACTS MAY CONSTITUTE FEDERAL CRIMINAL VIOLATIONS. 

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

[ ] APPLICATION [ ] AMENDMENT 

1. Exact name, principal business address, mailing address, if different, and telephone number of the applicant: 

A. Full name of the applicant: 

B. IRS Empl. Ident. No.: 

C. Applicant’s NFA ID #: Applicant’s CIK # (if any): Applicant’s UIC # (if any): 

FORM SBSE-A 

Page 1 

(Execution Page) 

WARNING: 

Application for Registration as a Security-based 

Swap Dealer and Major Security-based Swap 

Participant that is Registered or Registering with 

the CFTC as a Swap Dealer or Major Swap 

Participant 

 Date:__________ Applicant NFA Number: ___________ 

Failure to keep this form current and to file accurate supplementary information on a timely basis, or the failure to keep 

accurate books and records or otherwise to comply with the provisions of law applying to the conduct of business as an 

SBS Entity, would violate the Federal securities laws and the laws of the jurisdictions and may result in disciplinary, 

administrative, injunctive or criminal action. 

D. Applicant’s Main Address: (Do not use a P.O. Box) 

Number and Street 1: 

E. Mailing Address, if different: 

Number and Street 1: Number and Street 2: 

City: State: 

Number and Street 2: 

Country: Zip/Postal Code: 

F. Business Telephone Number: 

G Website/URL: 

H. Contact Employee: 

 Name: 

 Telephone Number: 

Title:

Email Address: 

I.	 Chief Compliance Officer designated by the applicant in accordance with Exchange Act Section 15F(k): 

 Name: Title:

 Telephone Number: Email Address: 

EXECUTION: 

The applicant consents that service of any civil action brought by or notice of any proceeding before the Securities and Exchange Commission in connection with the applicant’s security-based swap 

activities, unless the applicant is a nonresident SBS Entity , may be given by registered or certified mail or confirmed telegram to the applicant’s contact employee at the main address, or mailing 

address if different, given in Items 1E and 1F. If the applicant is a nonresident SBS Entity, it must complete Schedule F to designate a U.S. agent for service of process. 

The undersigned certifies that he/she has executed this form on behalf of, and with the authority of, said applicant. The undersigned and applicant represent that the information and statements 

contained herein, including schedules attached hereto, and other information filed herewith are current, true and complete. The undersigned and applicant further represent that to the extent any 

information previously submitted is not amended such information is currently accurate and complete. 

Date (MM/DD/YYYY) Name of Applicant 

By: 

Signature Name and Title of Person Signing on Applicant’s behalf 

This page must always be completed in full. 

DO NOT WRITE BELOW THIS LINE – FOR OFFICIAL USE ONLY 
Copy to Jack Habert, 12/28/201 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORM SBSE-A 

Page 2 

Applicant Name: _____________________________________ 

Date:__________ Applicant NFA No.: __________ 

Official Use Official 

Use 

Only 

2. A. The applicant is registering as a security-based swap dealer: [ ] Yes [ ] No 

B. The applicant is registering as a major security-based swap participant: [ ] Yes [ ] No 

Because it: (check all that apply) 

[ ] maintains a substantial security-based swap position 

[ ] has substantial counterparty exposure [ ] is highly leveraged relative to its capital position 

3. A. Is the applicant a foreign security-based swap dealer that intends to: 

 work with the Commission and its primary regulator to have the Commission determine whether the 

requirements of its primary regulator’s regulatory system are comparable to the Commission’s [ ] Yes [ ] No 

 avail itself of a previously granted substituted compliance determination [ ] Yes [ ] No 

with respect to the requirements of Section 15F of the Exchange Act of 1934 and the rules and regulations 

thereunder? 

B. If “yes” to either of the questions in Item 3.A. above, identify the foreign financial regulatory authority that serves 

as the applicant’s primary regulator and for which the Commission has made, or may make, a substituted 

compliance determination: 

____________________________________________________________________________________________ 

__________________________________________________________________________________. 

C. If the applicant is relying on a previously granted substituted compliance determination, please describe how the 

applicant satisfies any conditions the Commission may have placed on such substituted compliance 

determination: 

__________________________________________________________________________________________ 

____________________________________________________________________________________. 

4. Does the applicant intend to compute capital or margin, or price customer or proprietary positions, using mathematical 

models? [ ] Yes [ ] No 

5. A. The applicant is currently registered with the Commodity Futures Trading Commission as a: 

[ ] Swap Dealer [ ] Major Swap Participant 

B. The applicant is registering with the Commodity Futures Trading Commission as a: 

[ ] Swap Dealer [ ] Major Swap Participant 

6. Is the applicant a U.S. branch of a non-resident entity? [ ] Yes [ ] No 

If “yes,” identify the non-resident entity and its location: 

________________________________________________________________________________________________. 

7. Briefly describe the applicant’s business: ______________________________________________________________ 

_______________________________________________________________________________________________ 

_______________________________________________________________________________________________ 

_______________________________________________________________________________________________ 

_______________________________________________________________________________________________ 

8. Is the applicant subject to regulation by a prudential regulator, as defined in Section 1a(39) of the 

Commodity Exchange Act. If “yes,” identify the prudential regulator: ____________________________. 

YES NO 

[ ] [ ] 

9. Is the applicant registered with the Commission as an investment adviser? 

Applicant’s IARD #: _____________________________________

 [ ] [ ] 

10. A. Is the applicant registered with the Commodity Futures Trading Commission in any capacity other than 

as a swap dealer or major swap participant?

 B. If “yes,” as a: [ ] Futures Commission Merchant [ ] Introducing Broker 

[ ] Commodity Pool Operator [ ] Other: ________________________ 

[ ] [ ]

11. Does applicant engage in any other non-securities, financial services industry-related business? 

If “yes,” describe each other business briefly on Schedule B, Section I. 

[ ] [ ] 

12. Does the applicant hold or maintain any funds or securities to collateralize counterparty transactions? [ ] [ ] 
Copy to Jack Habert, 12/28/2011 

 

 

 

 

 

 

 

 

 

 

 

 

FORM SBSE-A 

Page 3 

Applicant Name: _____________________________________ 

Date:__________ Applicant NFA No.: __________ 

Official Use Official 

Use 

Only 

13. Does the applicant have any arrangement: 

A. With any other person, firm, or organization under which any books or records of the applicant are kept, 

maintained, or audited by such other person, firm or organization?

 B. Under which such other person, firm or organization executes, trades, custodies, clears or settles on 

behalf of the applicant (including any SRO in which the applicant is a member)? 

If “yes” to any part of Item 11, complete appropriate items on Schedule B, Section II.

YES NO 

[ ] [ ]

 [ ] [ ] 

14. Does any person directly or indirectly control the management or policies of the applicant through 

agreement or otherwise? 

If “yes,” complete appropriate item on Schedule B, Section II.

 [ ] [ ] 

15. Does any person directly or indirectly finance (wholly or partially) the business of the applicant? 

Do not answer “Yes” to Item 15 if the person finances the business of the applicant through: 1) a public 

offering of securities made pursuant to the Securities Act of 1933; or 2) credit extended in the ordinary 

course of business by suppliers, banks, and others. 

If “yes,” complete appropriate item on Schedule B, Section II.

 [ ] [ ] 

16. Is the applicant at the time of this filing succeeding to the business of a currently registered SBS Entity? 

If “yes,” complete appropriate items on Schedule B, Section III.

 [ ] [ ] 

17. Is the applicant registered with a foreign financial regulatory authority? 

If “yes,” list all such registrations on Schedule F, Page 1, Section II. 

[ ] [ ] 

18. The applicant has ______ principals who are individuals. 

Please list all principals who are individuals on Schedule A. 

19. Does any principal not identified in Item 18 and Schedule A effect, or is any principal not identified in Item 18 and 

Schedule A involved in effecting security-based swaps on behalf of the applicant, or will such principals effect or be 

involved in effecting such business on the applicant’s behalf? 

If “yes,” complete appropriate item on Schedule B, Section IV. 
Copy to Jack Habert, 12/28/201 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Schedule A of FORM 

SBSE-A 

PRINCIPALS THAT ARE 

INDIVIDUALS 

(Answer for Form SBSE-A Item 18) 

Applicant Name: ___________________________________ 

Date:__________ Applicant NFA No.: __________ 

Official Use 

Use Schedule A to identify all principals of the applicant who are individuals. 

Complete the “Title or Status” column by entering board/management titles; status as partner, trustee, sole proprietor, or 

shareholder; and for shareholders, the class of securities owned (if more than one is issued). 

Ownership Codes are: 

NA - less than 5% B - 10% but less than 25% D - 50% but less than 75%

 A - 5% but less than 10% C - 25% but less than 50% E - 75% or more 

FULL LEGAL NAME 

(Individuals: Last Name, First Name, Middle 

Name) 

Title or Status Date Title or 

Status Acquired 

Date Individual 

began working 

for applicant 

Does person 

have an 

ownership 

interest in 

the applicant 

If yes, 

include 

ownership 

code 

NFA Identification No., CRD No. 

and/or IARD No. 

Official 

Use 

Only 

MM YYYY MM YYYY 

1. Y / N 

For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior 

position - employer, job title, and dates of service): 

2. Y / N 

For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior 

position - employer, job title, and dates of service): 

3. Y / N 

For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior 

position - employer, job title, and dates of service): 

4. Y / N 

For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior 

position - employer, job title, and dates of service): 

5. Y / N 

For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior 

position - employer, job title, and dates of service): 

6. Y / N 

For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior 

position - employer, job title, and dates of service): 

7. Y / N 

For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior 

position - employer, job title, and dates of service): 

8. Y / N 

For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior 

position - employer, job title, and dates of service): 

9. Y / N 

For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior 

position - employer, job title, and dates of service): 

10. Y / N 

For individuals not presently registered through NFA, CRD or IARD, describe prior investment-related experience (e.g., for each prior 

position - employer, job title, and dates of service): 
Copy to Jack Habert, 12/28/201 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Schedule B of FORM 

SBSE-A 

Page 1 

Applicant Name: _____________________________________ 

Date:__________ Applicant NFA No.: __________ 

Official Use Official 

Use 

Only 

Use this Schedule B to report details for items listed below. Report only new information or changes/updates to 

previously submitted details. Do not repeat previously submitted information. 

This is an [ ] INITIAL [ ] AMENDED detail filing for the Form SBSE-A items checked below: 

Section I Other Business 

Item 11: Does applicant engage in any other non-securities, financial services industry-related business? 

UIC (if any), or other Unique Identification Number(s): Assigning Regulator(s)/Entity(s): 

Briefly describe any other financial services industry-related, non-securities business in which the applicant is engaged: 

Section II Record Maintenance Arrangements / Business Arrangements / Control Persons / Financings 

(Check one) [ ] Item 13A [ ] Item 13B [ ] Item 14 [ ] Item 15 

Applicant must complete a separate Schedule B Page 1 for each affirmative response in this section including any 

multiple responses to any item. Complete the “Effective Date” box with the Month, Day and Year that the arrangement 

or agreement became effective. When reporting a change or termination of an arrangement, enter the effective date 

of the change. 

Firm or Organization Name SEC File, CRD, NFA, IARD, UIC, and/or CIK Number (if 

any) 

Business Address (Street, City, State/Country, Zip + 4 Postal Code) Effective Date

 MM DD YYYY 

/ / 

Termination Date 

MM DD YYYY 

/ / 

Individual Name CRD, NFA, and/or IARD Number (if any) 

Business Address (if applicable) (Street, City, State/Country, Zip + 4 Postal Code) Effective Date

 MM DD YYYY 

/ / 

Termination Date 

MM DD YYYY 

/ / 

Briefly describe the nature of the arrangement with respect to books or records (ITEM 13A); the nature of the execution, trading, custody, clearing or 

settlement arrangement (ITEM 13B); the nature of the control or agreement (ITEM 14); or the method and amount of financing (ITEM 15). Use reverse 

side of this sheet for additional comments if necessary. 

For ITEM 14 ONLY - If the control person is an individual not presently registered through CRD or IARD, describe prior investment-related experience (e.g., for each prior position 

- employer, job title, and dates of service). 

Section III Successions 

Item 16: Is the applicant at the time of this filing succeeding to the business of a currently registered SBS Entity? 

Date of Succession MM DD YYYY 

/ / 

Name of Predecessor

SEC File, CRD, NFA, IARD, UIC, and/or CIK Number (if any) IRS Employer Number (if any) 

Briefly describe details of the succession including any assets or liabilities not assumed by the successor. Use reverse side of this sheet for additional 

comments if necessary. 

Section IV Principals Effecting or Involved in Effecting SBS Business 

Item 19: Does any principal not identified in Item 18 and Schedule A effect, or is any principal not identified in Item 15 

and Schedule A involved in effecting security-based swaps on behalf of the applicant, or will such principals effect or 

be involved in effecting such business on the applicant’s behalf? 

For each Principal identified in Section IV, complete Schedule D of the Form SBSE-A and the relevant DRP pages. 

1. Name of Principal Type of Entity (Corp, Partnership, 

LLC, etc.) 

SEC File No., CRD, NFA, IARD, CIK Number, UIC 

(if any), and/or Tax Identification Number 

Business Address (Street, City, State/Country, Zip + 4/Postal Code) 

This entity [ ] effects [ ] is involved in effecting security based swaps on behalf of the applicant. (check only 

one) 

Briefly describe the details of the principal’s activities relating to its effecting or involvement in effecting security-based swap transactions on behalf of the 

applicant: 
Copy to Jack Habert, 12/28/201 

 

 

 

 

 

 

 

Schedule B of FORM 

SBSE-A 

Page 2 

Applicant Name: _____________________________________ 

Date:__________ Applicant NFA No.: __________ 

Official Use Official 

Use 

Only 

Section IV, Continued Principals Effecting or Involved in Effecting SBS Business 

For each Principal identified in Section IV, complete Schedule D of the Form SBSE-A and the relevant DRP pages. 

2. Name of Principal Type of Entity (Corp, Partnership, 

LLC, etc.) 

SEC File No., CRD, NFA, IARD, CIK Number, UIC 

(if any), and/or Tax Identification Number 

Business Address (Street, City, State/Country, Zip + 4/Postal Code) 

This entity [ ] effects [ ] is involved in effecting security based swaps on behalf of the applicant. (check only one) 

Briefly describe the details of the principal’s activities relating to its effecting or involvement in effecting security-based 

swap transactions on behalf of the applicant: 

3. Name of Principal Type of Entity (Corp, Partnership, 

LLC, etc.) 

SEC File No., CRD, NFA, IARD, CIK Number, UIC 

(if any), and/or Tax Identification Number 

Business Address (Street, City, State/Country, Zip + 4/Postal Code) 

This entity [ ] effects [ ] is involved in effecting security based swaps on behalf of the applicant. (check only one) 

Briefly describe the details of the principal’s activities relating to its effecting or involvement in effecting security-based 

swap transactions on behalf of the applicant: 

4. Name of Principal Type of Entity (Corp, Partnership, 

LLC, etc.) 

SEC File No., CRD, NFA, IARD, CIK Number, UIC 

(if any), and/or Tax Identification Number 

Business Address (Street, City, State/Country, Zip + 4/Postal Code) 

This entity [ ] effects [ ] is involved in effecting security based swaps on behalf of the applicant. (check only one) 

Briefly describe the details of the principal’s activities relating to its effecting or involvement in effecting security-based 

swap transactions on behalf of the applicant: 

5. Name of Principal Type of Entity (Corp, Partnership, 

LLC, etc.) 

SEC File No., CRD, NFA, IARD, CIK Number, UIC 

(if any), and/or Tax Identification Number 

Business Address (Street, City, State/Country, Zip + 4/Postal Code) 

This entity [ ] effects [ ] is involved in effecting security based swaps on behalf of the applicant. (check only one) 

Briefly describe the details of the principal’s activities relating to its effecting or involvement in effecting security-based 

swap transactions on behalf of the applicant: 

6. Name of Principal Type of Entity (Corp, Partnership, 

LLC, etc.) 

SEC File No., CRD, NFA, IARD, CIK Number, UIC 

(if any), and/or Tax Identification Number 

Business Address (Street, City, State/Country, Zip + 4/Postal Code) 

This entity [ ] effects [ ] is involved in effecting security based swaps on behalf of the applicant. (check only one) 

Briefly describe the details of the principal’s activities relating to its effecting or involvement in effecting security-based 

swap transactions on behalf of the applicant: 
Copy to Jack Habert, 12/28/201 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Schedule D of 

FORM SBSE-A 

Page 1 

Applicant Name: ___________________________________ 

Principal Name: ____________________________________ 

Date:__________ Applicant NFA No.: __________ 

Official Use Official 

Use 

Only 

Use the appropriate DRP for providing details to “yes” answers to the questions in Schedule D. Refer to the 

Explanation of Terms section of Form SBSE-A Instructions for explanations of italicized terms. CRIMINAL DISCLOSURE 

A. In the past ten years has the principal: 

(1) Been convicted of or pled guilty or nolo contendere (“no contest”) in a domestic, foreign or military 

court to any felony? 

(2) Been charged with a felony

B. In the past ten years has the principal: 

(1) Been convicted of or pled guilty or or nolo contendere (“no contest”) in a domestic, foreign or military 

court to a misdemeanor involving: financial services industry-related business, or any fraud, false 

statements or omissions, wrongful taking of property, bribery, perjury, forgery, counterfeiting, 

extortion, or a conspiracy to commit any of these offenses?

(2) Been charged with a misdemeanor specified in B(1)? 

YES NO 

[ ] [ ] 

[ ] [ ] 

[ ] [ ] 

[ ] [ ] 

REGULATORY ACTIONDISCLOSURE 

C. Has the U.S. Securities and Exchange Commission or the Commodity Futures Trading Commission ever: 

(1) Found the principal to have made a false statement or omission?

(2) Found the principal to have been involved in a violation of its regulations or statutes? 

(3) Found the principal to have been a cause of a financial services industry-related business having its 

authorization to do business denied, revoked, or restricted? 

(4) Entered an order against the principal in connection with financial services industry-related activity? 

(5) Imposed a civil money penalty on the principal, or ordered the principal to cease and desist from any 

activity?

 [ ] [ ] 

[ ] [ ] 

[ ] [ ] 

[ ] [ ] 

[ ] [ ] 

REGULATORY ACTION DISCLOSURE 

D. Has any other federal regulatory agency, state regulatory agency, or foreign financial regulatory authority: 

(1) Ever found the principal to have made a false statement or omission or been dishonest, unfair, or 

unethical?

(2) Ever found the principal to have been involved in a violation of financial services industry-related 

regulations or statutes?

(3) Ever found the principal to have been a cause of a financial services industry-related business 

having its authorization to do business denied, suspended, revoked or restricted?

(4) In the past ten years, entered an order against the principal in connection with a financial services 

industry-related activity? 

(5) Ever denied, suspended, or revoked the principal’s registration or license or otherwise, by order, 

prevented it from associating with a financial services industry-related business or restricted its 

activities? 

E. Has any self-regulatory organization or commodities exchange ever: 

(1) found the principal to have made a false statement or omission?

(2) found the principal to have been involved in a violation of its rules (other than a violation designated 

as a “minor rule violation” under a plan approved by the U.S. Securities and exchange Commission)?

(3) found the principal to have been the cause of a financial services industry-related business having its 

authorization to do business denied, suspended, revoked or restricted?

 [ ] [ ] 

[ ] [ ] 

[ ] [ ] 

[ ] [ ] 

[ ] [ ] 

[ ] [ ] 

[ ] [ ] 

[ ] [ ] 

(4) Disciplined the principal by expelling or suspending it from membership, barring or suspending its 

association with other members, or otherwise restricting its activities?

F. Has the principal’s authorization to act as an attorney, accountant, or federal contractor ever been 

revoked or suspended?

G. Is the principal now the subject of any regulatory proceeding that could result in a “yes” answer to any 

part of C, D, or E? 

[ ] [ ] 

[ ] [ ] 

[ ] [ ] 
Copy to Jack Habert, 12/28/201 

 

 

 

 

 

 

 

Schedule D of 

FORM SBSE-A 

Page 2 

Applicant Name: ___________________________________ 

Principal Name: ____________________________________ 

Date:__________ Applicant NFA No.: __________ 

Official Use Official 

Use 

Only 

CIVIL JUDICIAL DISCLOSURE 

H. (1) Has any domestic or foreign civil judicial court: 

(a) In the past ten years, enjoined the principal in connection with any financial services 

industry-related activity? 

(b) Ever found that the principal was involved in a violation of financial services industry-related 

statutes or regulations?

 (c) Ever dismissed, pursuant to a settlement agreement, a financial services industry-related 

civil judicial action brought against the principal by a state or foreign financial regulatory 

authority? 

(2) Is the principal now the subject of any civil judicial proceeding that could result in a “yes” answer 

to any part of H(1)? 

YES NO 

[ ] [ ]

 [ ] [ ]

 [ ] [ ] 

[ ] [ ] 

FINANCIAL

DISCLOSURE 

I. In the past ten years has the principal ever been a securities firm or a principal of a securities firm 

that: 

(1) Has been the subject of a bankruptcy petition?

(2) Has had a trustee appointed or a direct payment procedure initiated under the Securities 

Investor Protection Act?

 [ ] [ ] 

[ ] [ ] 
Copy to Jack Habert, 12/28/201 

 

 

 

 

 

 

 

 

 

Schedule F of FORM 

SBSE-A 

Applicant Name: _________________________________ 

Date:__________ Applicant NFA No.: __________ 

Official Use 

Section I Service of Process and Certification Regarding Access to Records 

Each nonresident security-based swap dealer and non-resident security-based swap participant shall use Schedule F to identify 

its United States agent for service of process and the certify that it can as a matter of law, and will -

(1) provide the Commission with prompt access to its books and records, and 

(2) submit to onsite inspection and examination by the Commission. 

1. Service of Process: 

A. Name of United States person applicant designates and appoints as agent for service of process

 B. Address of United States person applicant designates and appoints as agent for service of process 

The above identified agent for service of process may be served any process, pleadings, subpoenas, or other papers in 

(a) any investigation or administrative proceeding conducted by the Commission that relates to the applicant or about which the 

applicant may have information; and 

(b) any civil or criminal suit or action or proceeding brought against the applicant or to which the applicant has been joined as 

defendant or respondent, in any appropriate court in any place subject to the jurisdiction of any state or of the United States or of 

any of its territories or possessions or of the District of Columbia, to enforce the Exchange Act. The applicant has stipulated and 

agreed that any such suit, action or administrative proceeding may be commenced by the service of process upon, and that 

service of an administrative subpoena shall be effected by service upon the above-named Agent for Service of Process, and that 

service as aforesaid shall be taken and held in all courts and administrative tribunals to be valid and binding as if personal 

service thereof had been made. 

2. Certification regarding access to records: 

Applicant can as a matter of law, and will; 

(1) provide the Commission with prompt access to its books and records, and 

(2) submit to onsite inspection and examination by the Commission. 

Applicant must attach to this Form SBSE a copy of the opinion of counsel it is required to obtain in accordance with 

paragraph (c)(2) or (c)(3) of Exchange Act Rule 15Fb2-4, as appropriate [paragraphs (c)(2) or (c)(3) of 17 CFR 

240.15Fb2-4]. 

Signature: 

Name and Title: 

Date: 

Section II Registration with Foreign Financial Regulatory Authorities 

Complete this Section for Registration with Foreign Financial Regulatory Authorities relating to ITEM 17. Each securitybased swap dealer and major security-based swap participant that is registered with a foreign financial regulatory authority must list on Section II 

of this Schedule F, for each foreign financial regulatory authority with which it is registered, the following information: 

1 

. ________________________________________________________ 

English Name of Foreign Financial Regulatory Authority 

___________________ 

Foreign Registration No. (if any) 

__________________ 

English Name of Country: 

2 

. ________________________________________________________ 

English Name of Foreign Financial Regulatory Authority 

___________________ 

Foreign Registration No. (if any) 

__________________ 

English Name of Country: 

3 

. ________________________________________________________ 

English Name of Foreign Financial Regulatory Authority 

___________________ 

Foreign Registration No. (if any) 

__________________ 

English Name of Country: 

If applicant has more than 3 Foreign Financial Regulatory Authorities to report, complete additional Schedule F Page 1s. 
 

Copy to Jack Habert, 12/28/201 

 

 

 

CRIMINAL DISCLOSURE REPORTING PAGE (SBSE-A) 

GENERAL INSTRUCTIONS 

This Disclosure Reporting Page [DRP (SBSE)] is an [ ] INITIAL OR [ ] AMENDED response to report details for 

affirmative responses to Items A and B of Schedule D of Form SBSE-A; 

Check [√] item(s) being responded to: 

A. In the past ten years has the principal: 

[ ] (1) Been convicted of or pled guilty or nolo contendere (“no contest”) in a domestic, foreign or military 

court to any felony? 

[ ] (2) Been charged with a felony? 

B. In the past ten years has the principal: 

[ ] (1) Been convicted of or pled guilty or or nolo contendere (“no contest”) in a domestic, foreign or military 

court to a misdemeanor involving: investments or an investment-related business, or any fraud, false 

statements or omissions, wrongful taking of property, bribery, perjury, forgery, counterfeiting, extortion, or a 

conspiracy to commit any of these offenses? 

[ ] (2) Been charged with a misdemeanor specified in B(1)? 

Use a separate DRP for each event or proceeding. An event or proceeding may be reported for more than one person or 

entity using one DRP. File with a completed Execution Page. 

Multiple counts of the same charge arising out of the same event(s) should be reported on the same DRP. Unrelated 

criminal actions, including separate cases arising out of the same event, must be reported on separate DRPs. Use this 

DRP to report all charges arising out of the same event. One event may result in more than one affirmative answer to the 

above items. 

If a principal is an organization registered through the CRD, such principal need only complete Part I of the applicant’s 

appropriate DRP (SBSE-A). Details of the event must be submitted on the principal’s appropriate DRP (BD) or DRP (U-4). 

If a principal is an individual or organization not registered through the CRD, provide complete answers to all the items on 

the applicant’s appropriate DRP (SBSE-A). The completion of this DRP does not relieve the principal of its obligation to 

update its CRD records. 

Applicants must attach a copy of each applicable court document (i.e., criminal complaint, information or indictment as well 

as judgment of conviction or sentencing documents) if not previously submitted through CRD (as they could be in the case 

of a control affiliate registered through CRD). Documents will not be accepted as disclosure in lieu of answering the 

questions on this DRP. 

PART I 

A. If the principal is registered with the CRD, provide the CRD number. If not, indicate “non-registered” by checking the 

appropriate checkbox. 

Name of Principal 

CRD NUMBER 

Registered: [ ] Yes [ ] No 

[ ] This DRP should be removed from the SBS Entity’s record because the principal is no longer associated with 

the SBS Entity. 

B. If the principal is registered through the CRD, has the principal submitted a DRP (with Form U-4) or DRP (BD) to the 

CRD System for the event? 

If the answer is “Yes,” no other information on this DRP must be provided: If “No,” complete Part II.
 

[ ] Yes [ ] No
 

Note: The completion of this Form does not relieve the principal of its obligation to update its CRD records. 
 

 

 

Copy to Jack Habert, 12/28/201 

 

___________________________________________________________________________________________ 

____________________________________________________________________________________________ 

 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

CRIMINAL DISCLOSURE REPORTING PAGE (SBSE-A) 

(continuation) 

PART II 

1. If charge(s) were brought against an organization over which the principal exercise(d) control: Enter organization 

name, whether or not the organization was an investment-related business and the principal’s position, title or 

relationship. 

2. Formal Charge(s) were brought in: (include name of Federal, Military, State or Foreign Court, Location of Court – City 

or County and State or Country, Docket/Case number). 

3. Event Disclosure Detail (Use this for both organizational and individual charges.) 

A. Date First Charged (MM/DD/YYYY): [ ] Exact [ ] Explanation 

If not exact, provide explanation: _________________________________________________________________

 B. Event Disclosure Detail (include Charge(s)/Charge Description(s), and for each charge provide: 1. number of 

counts, 2. felony or misdemeanor, 3. plea for each charge, and 4. product type if charge is investment-related):

 ___________________________________________________________________________________________ 

C. Current status of the Event? [ ] Pending [ ] On Appeal [ ] Final

 D. Event Status Date (complete unless status is [ ] Exact [ ] Explanation 

Pending) (MM/DD/YYYY): 

If not exact, provide explanation: _________________________________________________________________ 

4. Disposition Disclosure Detail: Include for each charge, A. Disposition Type [e.g., convicted, acquitted, dismissed, 

pretrial.], B. Date, C. Sentence/Penalty, D. Duration [if sentence-suspension, probation, etc.], E. Start Date of Penalty, 

F. Penalty/Fine Amount and G. Date Paid.

 ___________________________________________________________________________________________ 

5. Provide a brief summary of the circumstances leading to the charge(s) as well as the disposition. Include the relevant 

dates when the conduct which was the subject of the charge(s) occurred. (The information must fit within the space 

provided.) 
 

Copy to Jack Habert, 12/28/201 

 

 

 

 

 

 

 

 

 

REGULATORY ACTION DISCLOSURE REPORTING PAGE (SBSE-A) 

GENERAL INSTRUCTIONS 

This Disclosure Reporting Page [DRP (SBSE)] is an [ ] INITIAL OR [ ] AMENDED response to report details for affirmative 

responses to Items C, D, E, F, or G of Schedule D of Form SBSE-A; 

Check [√] item(s) being responded to: 

C. Has the U.S. Securities and Exchange Commission or the Commodity Futures Trading Commission ever: 

[ ] (1) Found the principal to have made a false statement or omission? 

[ ] (2) Found the principal to have been involved in a violation of its regulations or statutes? 

[ ] (3) the principal to have been a cause of an investment-related business having its authorization to do business denied, revoked, or restricted? 

[ ] (4) Entered an order against the principal in connection with investment-related activity? 

[ ] (5) Imposed a civil money penalty on the principal, or ordered the principal to cease and desist from any activity? 

D. Has any other federal regulatory agency, state regulatory agency, or foreign financial regulatory authority: 

[ ] (1) Ever found the principal to have made a false statement or omission or been dishonest, unfair, or unethical? 

[ ] (2) Ever found the principal to have been involved in a violation of investment-related regulations or statutes? 

[ ] (3) Ever found the principal to have been a cause of an investment-related business having its authorization to do business denied, suspended, revoked or 

restricted? 

[ ] (4) In the past ten years, entered an order against the principal in connection with an investment-related activity? 

[ ] (5) Ever denied, suspended, or revoked the principal’s registration or license or otherwise, by order, prevented it from associating with an investment-related 

business or restricted its activities? 

E. Has any self-regulatory organization or commodities exchange ever: 

[ ] (1) found the principal to have made a false statement or omission? 

[ ] (2) found the principal to have been involved in a violation of its rules (other than a violation designated as a “minor rule violation” under a plan approved by the 

U.S. Securities and exchange Commission)? 

[ ] (3) found the principal to have been the cause of an investment-related business having its authorization to do business denied, suspended, revoked or restricted? 

[ ] (4) Disciplined the principal by expelling or suspending it from membership, barring or suspending its association with other members, or otherwise restricting its 

activities? 

F. [ ] Has the principal’s authorization to act as an attorney, accountant, or federal contractor ever been revoked or suspended? 

G. [ ] Is the principal now the subject of any regulatory proceeding that could result in a “yes” answer to any part of C, D, or E? 

Use a separate DRP for each event or proceeding. An event or proceeding may be reported for more than one person or entity using one 

DRP. File with a completed Execution Page. 

One event may result in more than one affirmative answer to Items C, D, E, F or G. Use only one DRP to report details related to the same 

event. If an event gives rise to actions by more than one regulator, provide details for each action on a separate DRP. 

It is not a requirement that documents be provided for each event or proceeding. Should they be provided, they will not be accepted as 

disclosure in lieu of answering the questions on this DRP. 

If the principal is an organization registered through the CRD, such principal need only complete Part I of the applicant’s appropriate DRP 

(SBSE). Details of the event must be submitted on the principal’s appropriate DRP (BD) or DRP (U-4). If a principal is an organization not 

registered through the CRD, provide complete answers to all the items on the applicant’s appropriate DRP (SBSE). The completion of this 

DRP does not relieve the prinicipal of its obligation to update its CRD records. 

PART I 

A. If the principal is registered with the CRD, provide the CRD number. If not, indicate “non-registered” by checking the 

appropriate checkbox. 

Name of Principal Principal’s CRD Number 

Registered: [ ] Yes [ ] No 

[ ] This DRP should be removed from the SBS Entity record because the control affiliate(s) are no longer associated 

with the SBS Entity. 

B. If the principal is registered through the CRD, has the principal submitted a DRP (with Form U-4) or DRP (BD) to the 

CRD System for the event? 

If the answer is “Yes,” no other information on this DRP must be provided: If “No,” complete Part II.
 

[ ] Yes [ ] No
 

Note: The completion of this Form does not relieve the principal of its obligation to update its CRD records. 
Copy to Jack Habert, 12/28/201 

 

 

 

____________________________________________________________________________________________ 

____________________________________________________________________________________________ 

____________________________________________________________________________________________ 

 

 

 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

 

REGULATORY ACTION DISCLOSURE REPORTING PAGE (SBSE-A) 

(continuation) 

PART II 

1. Regulatory Action initiated by: 

[ ] SEC [ ] Other Federal [ ] State [ ] SRO [ ] Foreign 

(Full name of regulator, foreign financial regulatory authority, federal, state or SRO) 

2. Principal Sanction: (check appropriate item) 

[ ] Civil and Administrative Penalty(ies)/Fine(s) [ ] Disgorgement [ ] Restitution 

[ ] Bar [ ] Expulsion [ ] Revocation 

[ ] Cease and Desist [ ] Injunction [ ] Suspension 

[ ] Censure [ ] Prohibition [ ] Undertaking 

[ ] Denial [ ] Reprimand [ ] Other ____________________ 

Other Sanctions: 

3. 

3. Date Initiated (MM/DD/YYYY) [ ] Exact [ ] Explanation 

If not exact, provide explanation: __________________________________________________________________ 

4. Docket/Case Number: 

5. Principal Employing Firm when activity occurred which led to the regulatory action (if applicable): 

6. Principal Product Type: (check appropriate item) 

[ ] Annuity(ies) - Fixed [ ] Debt - Municipal [ ] Investment Contract(s) 

[ 

[ 

[ 

[ 

[ 

[ 

[ 

] Annuity(ies) - Variable 

] Banking Products (other 

than CD(s)) 

] CD(s) 

] Commodity Option(s) 

] Debt – Asset Backed 

] Debt - Corporate 

] Debt - Government 

[ 

[ 

[ 

[ 

[ 

[ 

[ 

[ 

] Derivative(s) 

] Direct Investment(s) – DPP & LP Interest(s) 

] Equity - OTC 

] Equity Listed (Common & Preferred Stock) 

] Futures - Commodity 

] Futures - Financial 

] Index Option(s) 

] Insurance 

[ 

[ 

[ 

[ 

[ 

[ 

[ 

] Money Market Fund(s) 

] Mutual Fund(s) 

] No Product 

] Options 

] Penny Stock(s) 

] Unit Investment Trust(s) 

] Other _________________ 

Other Product Type: 

7. Describe the allegations related to this regulatory action. (The information must fit within the space provided.): 

8. Current Status? [ ] Pending [ ] On Appeal [ ] Final 

9. If on appeal, regulatory action appealed to: (SEC, SRO, Federal or State Court) and Date Appeal Filed: 
 

Copy to Jack Habert, 12/28/201 

 

 

 

 

 

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___________________________________________________________________________________________ 

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REGULATORY ACTION DISCLOSURE REPORTING PAGE (SBSE-A) 

(continuation) 

If Final or On Appeal, complete all items below. For Pending Actions, complete Item 13 only. 

10. How was matter resolved: (check appropriate item) 

[ ] Acceptance, Waiver & Consent (AWC) [ ] Consent [ ] Settled 

[ ] Decision & Order of Offer of Settlement [ ] Dismissed [ ] Stipulation and Consent 

[ ] Decision [ ] Order [ ] Vacated 3. 

11. Resolution Date (MM/DD/YYYY) [ ] Exact [ ] Explanation 

If not exact, provide explanation: 

12. A. Were any of the following Sanctions Ordered? (Check all appropriate items): 

[ ] Monetary/Fine [ ] Revocation/Expulsion/Denial [ ] Disgorgement/Restitution 

Amount $________ [ ] Censure [ ] Cease and Desist/Injunction [ ] Bar [ ] Suspension 

B. Other Sanctions Ordered: 

C. Sanction Detail: If suspended, enjoined or barred, provide duration including start date and capacities affected 

(General Securities Principal, Financial Operations Principal, etc.). If requalification, by exam/retraining was a 

condition of the sanction, provide length of time given to re-qualify/retrain, type of exam required and whether 

condition has been satisfied. If disposition resulted in a fine, penalty, restitution, disgorgement or monetary 

compensation, provide total amount, portion levied against principal, date paid and if any portion of penalty was 

waived. 

13. Provide a brief summary of details related to the action status and (or) disposition and include relevant terms, 

conditions and dates. (The information must fit within the space provided.) 
 

Copy to Jack Habert, 12/28/201 

 

 

 

 

CIVIL JUDICIAL ACTION DISCLOSURE REPORTING PAGE (SBSE-A) 

GENERAL INSTRUCTIONS 

This Disclosure Reporting Page [DRP (SBSE-A)] is an [ ] INITIAL OR [ ] AMENDED response to report details for 

affirmative responses to Item H of Schedule D of Form SBSE-A; 

Check [√] item(s) being responded to: 

H(1) Has any domestic or foreign civil judicial court: 

[ ] (a) in the past ten years, enjoined the principal in connection with any investment-related activity? 

[ ] (b) ever found that the principal was involved in a violation of investment-related statutes or 

regulations? 

[ ] (c) ever dismissed, pursuant to a settlement agreement, an investment-related civil judicial action 

brought against the principal by a state or foreign financial regulatory authority? 

H(2) [ ] Is the principal now the subject of any civil judicial proceeding that could result in a “yes” answer to any 

part of H? 

Use a separate DRP for each event or proceeding. An event or proceeding may be reported for more than one person or entity using one 

DRP. File with a completed Execution Page. 

One event may result in more than one affirmative answer to Item H. Use only one DRP to report details related to the same event. 

Unrelated civil judicial actions must be reported on separate DRPs. 

It is not a requirement that documents be provided for each event or proceeding. Should they be provided, they will not be accepted as 

disclosure in lieu of answering the questions on this DRP. 

If a principal is an individual or organization registered through the CRD, such principal need only complete Part I of the applicant’s 

appropriate DRP (SBSE-A). Details of the event must be submitted on the principal’s appropriate DRP (BD) or DRP (U-4). If a principal is an 

organization not registered through the CRD, provide complete answers to all the items on the applicant’s appropriate DRP (SBSE-A). The 

completion of this DRP does not relieve the principal of its obligation to update its CRD records. 

PART I 

A. If the principal is registered with the CRD, provide the CRD number. If not, indicate “non-registered” by checking the 

appropriate checkbox. 

Name of Principal 

CRD NUMBER 

Registered: [ ] Yes [ ] No 

[ ] This DRP should be removed from the SBS Entity’s record because the principal is no longer associated with the 

SBS Entity. 

B. If the principal is registered through the CRD, has the principal submitted a DRP (with Form U-4) or DRP (BD) to the 

CRD System for the event? 

If the answer is “Yes,” no other information on this DRP must be provided: If “No,” complete Part II.
 

[ ] Yes [ ] No
 

Note: The completion of this Form does not relieve the principal of its obligation to update its CRD records. 
Copy to Jack Habert, 12/28/201 

 

____________________________________________________________________________________________ 

____________________________________________________________________________________________ 

____________________________________________________________________________________________ 

 

 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

 

_____________________________________________________________________________________________ 

 

CIVIL JUDICIAL ACTION DISCLOSURE REPORTING PAGE (SBSE-A) 

(continuation) 

PART II 

1. Court Action initiated by: (Name of regulator, foreign financial regulatory authority, SRO, commodities exchange, 

agency, firm, private plaintiff, etc.) 

2. Principal Relief Sought: (check appropriate item) 

[ ] Cease and Desist [ ] Disgorgement [ ] Money Damages (Private/Civil Complaint) [ ] Restraining Order 

[ ] Civil Penalty(ies)/Fine(s) [ ] Injunction [ ] Restitution [ ] Other __________ 

Other Relief Sought: 

3. 

3. Filing Date of Court Action (MM/DD/YYYY) [ ] Exact [ ] Explanation 

If not exact, provide explanation: __________________________________________________________________ 

4. Principal Product Type: (check appropriate item) 

[ ] Annuity(ies) - Fixed [ ] Debt - Municipal [ ] Investment Contract(s) 

[ ] Annuity(ies) - Variable [ ] Derivative(s) [ ] Money Market Fund(s) 

[ ] Banking Products (other [ ] Direct Investment(s) – DPP & LP Interest(s) [ ] Mutual Fund(s) 

than CD(s)) [ ] Equity - OTC [ ] No Product 

[ ] CD(s) [ ] Equity Listed (Common & Preferred Stock) [ ] Options 

[ ] Commodity Option(s) [ ] Futures - Commodity [ ] Penny Stock(s) 

[ ] Debt – Asset Backed [ ] Futures - Financial [ ] Unit Investment Trust(s) 

[ ] Debt - Corporate [ ] Index Option(s) [ ] Other _________________ 

[ ] Debt - Government [ ] Insurance 

Other Product Type: 

5. Formal Action was brought in (include name of Federal, State or Foreign Court, Location of Court – City or County and 

State or Country, Docket/Case Number): 

6. Control Affiliate Employing Firm when activity occurred which led to the civil judicial action (if applicable): 

7. Describe the allegations related to this civil action. (The information must fit within the space provided.): 

8. Current Status? [ ] Pending [ ] On Appeal [ ] Final 

9. If on appeal, action appealed to (provide name of court): Date Appeal Filed (MM/DD/YYYY): 

10. If pending, date notice/process was served (MM/DD/YYYY) [ ] Exact [ ] Explanation 

If not exact, provide explanation: 
 

Copy to Jack Habert, 12/28/201 

 

 

 

 

 

 

___________________________________________________________________________________________ 

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___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

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___________________________________________________________________________________________ 

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CIVIL JUDICIAL ACTION DISCLOSURE REPORTING PAGE (SBSE-A) 

(continuation) 

If Final or On Appeal, complete all items below. For Pending Actions, complete Item 14 only. 

11. How was matter resolved: (check appropriate item) 

[ ] Consent [ ] Judgement Rendered [ ] Settled 

[ ] Dismissed [ ] Opinion [ ] Withdrawn [ ] Other _______________________
 

3. 

12. Resolution Date (MM/DD/YYYY) [ ] Exact [ ] Explanation 

If not exact, provide explanation: 

13. Resolution Detail 

A. Were any of the following Sanctions Ordered or Relief Granted? (Check all appropriate items): 

[ ] Monetary/Fine [ ] Revocation/Expulsion/Denial [ ] Disgorgement/Restitution 

Amount $________ [ ] Censure [ ] Cease and Desist/Injunction [ ] Bar [ ] Suspension 

B. Other Sanctions: 

C. Sanction Detail: If suspended, enjoined or barred, provide duration including start date and capacities affected 

(General Securities Principal, Financial Operations Principal, etc.). If requalification, by exam/retraining was a 

condition of the sanction, provide length of time given to re-qualify/retrain, type of exam required and whether 

condition has been satisfied. If disposition resulted in a fine, penalty, restitution, disgorgement or monetary 

compensation, provide total amount, portion levied against prinicpal, date paid and if any portion of penalty was 

waived. 

14. Provide a brief summary of details related to action(s), allegation(s), disposition(s), and/or finding(s) disclosed above. 

(The information must fit within the space provided.) 
 

 

 

 

 

BANKRUPTCY / SIPC DISCLOSURE REPORTING PAGE (SBSE-A)
 GENERAL INSTRUCTIONS 

This Disclosure Reporting Page [DRP (SBSE-A)] is an an [ ] INITIAL OR [ ] AMENDED response to report details for 

affirmative responses to Questions I on Schedule D of Form SBSE-A; 

Check [√] item(s) being responded to: 

l In the past ten years has the principal ever been a securities firm or a control affiliate of a securities firm that: 

[ ] (1) has been the subject of a bankruptcy petition? 

[ ] (2) has had a trustee appointed or a direct payment procedure initiated under the Securities Investor 

Protection Act? 

Use a separate DRP for each event or proceeding. An event or proceeding may be reported for more than one person or 

entity using one DRP. File with a completed Execution Page. 

It is not a requirement that documents be provided for each event or proceeding. Should they be provided, they will not be 

accepted as disclosure in lieu of answering the questions on this DRP. 

If a principal is an individual or organization registered through CRD, such principal need only complete Part I of the 

applicant’s appropriate DRP (SBSE-A). Details of the event must be submitted on the principal’s appropriate DRP (BD) or 

DRP (U-4). If a principal is an organization not registered through the CRD, provide complete answers to all the items on the 

applicant’s appropriate DRP (SBSE-a). The completion of this DRP does not relieve the prinicpal of its obligation to update its 

CRD records. 

PART I 

A. If the principal is registered with the CRD, provide the CRD number. If not, indicate “non-registered” by checking the 

appropriate checkbox. 

Name of Principal 

CRD NUMBER 

Registered: [ ] Yes [ ] No 

[ ] This DRP should be removed from the SBS Entity’s record because the principal is no longer associated with the 

SBS Entity. 

B. If the principal is registered through the CRD, has the principal submitted a DRP (with Form U-4) or DRP (BD) to the 

CRD System for the event? 

If the answer is “Yes,” no other information on this DRP must be provided: If “No,” complete Part II.
 

[ ] Yes [ ] No
 

Note: The completion of this Form does not relieve the principal of its obligation to update its CRD records. 

PART II 

Action Type: (check appropriate item) 

[ ] Bankruptcy [ ] Declaration [ ] Receivership 

[ ] Compromise [ ] Liquidated [ ] Other ____________________
 

1. 

2. Action Date (MM/DD/YYYY) ______________________ [ ] Exact [ ] Explanation 

If not exact, provide explanation: _____________________________________________________________ 
 

 

 

 

 

Copy to Jack Habert, 12/28/201 

 

 

 

 

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BANKRUPTCY / SIPC DISCLOSURE REPORTING PAGE (SBSE-A)

(continuation) 

3. If the financial action relates to an organization over which the applicant or the control affiliate exercise(d) control, 

enter organization name and the applicant’s or control affiliate’s position, title or relationship: 

 ________________________________________________________________________________________ 

Was the Organization investment-related? [ ] Yes [ ] No 

4. Court action brought in (Name of Federal, State or Foreign Court), Location of Court (City or County and State or 

Country), Docket/Case Number and Bankruptcy Chapter Number (if Federal Bankruptcy Filing): 

 ________________________________________________________________________________________ 

5. Is action currently pending? [ ] Yes [ ] No 

6. If not pending, provide Disposition Type: (check appropriate item) 

[ ] Direct Payment Procedure [ ] Dismissed [ ] Satisfied/Released 

[ ] Discharged [ ] Dissolved [ ] SIPA Trustee Appointed [ ] Other _____________ 

7. Disposition Date (MM/DD/YYYY): _______________________ [ ] Exact [ ] Explanation 

If not exact, provide explanation: _____________________________________________________________ 

8. Provide a brief summary of events leading to the action and if not discharged, explain. (The information must fit 

within the space provided.): 

9. If a SIPA trustee was appointed or a direct payment procedure was begun, enter the amount paid or agreed to be 

paid by you; or the name of the trustee: 

Currently open? [ ] Yes [ ] No 

Date Direct Payment Initiated/Filed or Trustee Appointed (MM/DD/YYYY): __________ [ ] Exact [ ] Explanation 

If not exact, provide explanation: _________________________________________________________________ 

10.	 Provide details of any status/disposition. Include details of creditors, terms, conditions, amounts due and settlement 

schedule (if applicable). (The information must fit within the space provided.)