Inability to Pay: Rule, Instructions, and Form D-A

A respondent who claims inability to pay monetary sanctions should read the below rule and 

instructions, and complete and file the attached Form D-A together with the required 

attachments listed on page 7, section K, of the form.

Rule 630. Inability to pay disgorgement, interest or penalties. 

(a) Generally. In any proceeding in which an order requiring payment of disgorgement, interest or

penalties may be entered, a respondent may present evidence of an inability to pay disgorgement, 

interest or a penalty. The Commission may, in its discretion, or the hearing officer may, in his or her 

discretion, consider evidence concerning ability to pay in determining whether disgorgement, interest 

or a penalty is in the public interest. 

(b) Financial disclosure statement. Any respondent who asserts an inability to pay disgorgement,

interest or penalties may be required to file a sworn financial disclosure statement and to keep the 

statement current. The financial statement shall show the respondent's assets, liabilities, income or 

other funds received and expenses or other payments, from the date of the first violation alleged 

against that respondent in the order instituting proceedings, or such later date as specified by the 

Commission or a hearing officer, to the date of the order requiring the disclosure statement to be 

filed. By order, the Commission or the hearing officer may prescribe the use of the Disclosure of 

Assets and Financial Information Form (see Form D-A at § 209.1 of this chapter) or any other form, 

may specify other time periods for which disclosure is required, and may require such other 

information as deemed necessary to evaluate a claim of inability to pay. 

(c) Confidentiality. Any respondent submitting financial information pursuant to this rule or Rule

410(c) may make a motion, pursuant to Rule 322, for the issuance of a protective order against 

disclosure of the information submitted to the public or to any parties other than the Division of 

Enforcement. Prior to a ruling on the motion, no party receiving information as to which a motion 

for a protective order has been made may transfer or convey the information to any other person 

without the prior permission of the Commission or the hearing officer. 

(d) Service required. Notwithstanding any provision of Rule 322, a copy of the financial disclosure

statement shall be served on the Division of Enforcement. 

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(e) Failure to file required financial information: sanction. Any respondent who, after making a claim of

inability to pay either disgorgement, interest or a penalty, fails to file a financial disclosure statement 

when such a filing has been ordered or is required by rule may, in the discretion of the Commission 

or the hearing officer, be deemed to have waived the claim of inability to pay. No sanction pursuant 

to Rule 155 or 180 shall be imposed for a failure to file such a statement. 

FORM D-A 

17 CFR 209.1 Form D-A: Disclosure of assets and financial information.

(a) Rules 410 and 630 of the Rules of Practice (17 CFR 201.410 and 201.630) provide that under

certain circumstances a respondent who asserts or intends to assert an inability to pay disgorgement, 

interest or penalties may be required to disclose certain financial information. Unless otherwise 

ordered, this form may be used by individuals required to supply such information. 

(b) The respondent filing Form D-A is required promptly to notify the Commission of any

material change in the answer to any question on this form. 

(c) Form D-A may not be withheld from the interested division. A respondent making financial

information disclosures on this form after the institution of proceedings may make a motion, 

pursuant to Rule 322 of the Commission's Rules of Practice (17 CFR 201.322), for the issuance of a 

protective order to limit disclosure to the public or parties other than the interested division of the 

information submitted on Form D-A. A request for a protective order allows the requester an 

opportunity to justify the need for confidentiality. The making of a motion for a protective order, 

however, does not guarantee that disclosure will be limited.

(d) No party receiving information for which a motion for a protective order has been made

may transfer or convey the information to any other person prior to a ruling on the motion without 

the prior permission of the Commission or a hearing officer.

(e) A person making financial information disclosures on Form D-A prior to the institution of

proceedings, in connection with an offer of settlement or otherwise, may request confidential 

treatment of the information pursuant to the Freedom of Information Act. See the Commission's 

Freedom of Information Act ("FOIA") regulations, 17 CFR 200.83. A request for confidential 

treatment allows the requester an opportunity to substantiate the need for confidentiality. No 

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determination as to the validity of any request for confidential treatment will be made until a request

for disclosure of the information under FOIA is received.

FORM D-A 

Model Disclosure of Assets and Financial Information Form

Instructions: The Commission's Rules of Practice provide that under certain circumstances a

respondent who asserts or intends to assert an inability to pay disgorgement, interest or penalties 

may be required to disclose certain financial information. See Rules 410 and 630. Unless otherwise

ordered, this form may be used by individuals required to supply such information. Partnerships, 

corporations or other entities should submit a financial statement, including an income statement,

balance sheet and federal tax returns for each year from the year of the earliest violation alleged

against the entity in the order instituting proceedings to the present. 

The respondent filing this form is required promptly to notify the Commission of any material 

change in the answer to any question on this form. 

A respondent making financial information disclosures on this form or in another manner 

pursuant to the requirements of Rule 410 or Rule 630 may submit the form with a motion for a

protective order pursuant to Rule 322 of the Commission's Rules of Practice. Any other person 

submitting this form may request that the Commission afford the information submitted 

confidential treatment under the Freedom of Information Act under the Commission's Freedom of 

Information Act ("FOIA") regulations, see 17 CFR 200.83. A request for confidential treatment

allows the requester an opportunity to justify the need for confidentiality. A request for confidential 

treatment does not, however, guarantee confidentiality. 

Notwithstanding any request for a protective order or for confidential treatment, copies of the 

financial disclosure statement shall be served on the interested division and will be included in the 

record of the proceeding. See Rule 630(d). If confidential treatment is sought, notice that a financial 

disclosure statement and request for confidential treatment have been filed shall be served on all 

other parties. 

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No party receiving information for which confidential treatment has been requested may

transfer or convey the information to any person or entity not a party to the proceeding without the 

prior permission of the Commission or a hearing officer. 

Complete and file the Form D-A that begins on the next page.

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_______________________________ 

 

 

	 	 	 	 	 	 	 	

United States of America
 

Before the
 

Securities and Exchange Commission
 

) 

In the Matter of ) Administrative 

) Proceeding File No. 

____________ ) 3- ___________

) 

_______________________________ ) 

Part I: Summary Financial Disclosure Statement 

Full Name: ________________________ ______________________ _______________________ Last	 First Middle 

A. Net Worth

1. Assets: (from Part II.B.) ________________________ 

2. Liabilities: (from Part II.C.) ________________________ 

3. Net Worth: (from Part II.D.) ________________________ 

B. Income and Payments Received

1. Gross income reported on most recent federal tax filing: ________________________ 

2. Last 12 calendar months (from Part II.E.): ________________________* 

* If this amount, divided by 12, does not equal your current monthly income, please explain

the discrepancy on an attached sheet.

C. Expenses

1. Last 12 calendar months (from Part II.F.): ________________________* 

* If this amount, divided by 12, does not equal your current monthly expenses, please 

explain the discrepancy on an attached sheet. 

1
United States of America
 

Before the
 

Securities and Exchange Commission
 

_______________________________ 

) 

In the Matter of ) Administrative 

) Proceeding File No. 

____________ ) 3- ___________

) 

_______________________________ ) 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 		 	 	 	 	 	 	 	 	 	

		 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	

 ______________________________ 

Part II: Detailed Financial Disclosure Information 

Full Name: ________________________ ______________________ _______________________ Last First Middle 

If this form is filled out by a respondent requesting a protective order pursuant to Rule of Practice 322 (17 CFR 201.322),

please check the box below. 

PROTECTIVE ORDER REQUESTED. Disclosure of this document is prohibited unless specifically authorized

below. This document should be placed in a nonpublic file.

For Use Only by the Secretary of the Commission:

By order of ________________ , the Commission authorized this form to be placed in a public file.

 Date 

Secretary’s Signature

2


Last name _______________________

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

 ___________________________ __________ 

 ___________________________ __________ 

 ___________________________ __________ 

 ___________________________ __________ 

A. Scope of Information Requested

Requests for information about you include a request for the same information about your spouse (unless you are legally

separated and living apart), minor children and any other dependents. 

B. Assets

List all assets owned by you, directly or indirectly, and all 

assets that are subject to your enjoyment or control, 

regardless of whether legal title or ownership is held in your 

name.
 

1. Cash

2. Listed Securities

3. Surrender Value of Insurance

		4. Loans, Notes, Accounts Receivable

Due to You

		5. Real Estate

6. Furniture

7. Jewelry, Art, Rugs, Silver		Collectibles,

Other Valuables

8. Automobiles

9. Unlisted Securities

10. Partnership Interests (non-securities)

11. Net Value of Ownership Interest

in Business

12. IRA, Keogh, 401(k), Annuity or

Pension Accounts

13. Other (Itemize):

14. Total Assets

C. Liabilities

List all your liabilities including, but not limited to, the items 

listed below.
 

1. Mortgages

2. Auto Loans

3. Credit Card Debt

4. Margin Loans

5. Insurance Policy Loans

6. Installment Loans

7. Other Loans, Notes or Accounts Payable

8. Accrued Real Estate Taxes

9. Judgments/Settlements Owed

10. Other (Itemize):

11. Total Liabilities

___________ 

___________ 

___________ 

___________ 

___________ 

___________ 

___________ 

___________ ___________ 

___________ ___________ 

___________ ___________ 

___________ 

___________ 

___________ 

___________ 

___________ 

___________ 

___________ 

___________ 

___________ ___________ 

D. Net Worth (assets minus liabilities) _________________ 

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Last name _______________________

 

 

 

 

 

 

	 	 	 	

	 	

 

	 	 	 	 	 	

	 	

___________________________ _____________________________ ____________ 

___________________________ _____________________________ ____________ 

 

 

____________ 

_____________________________ ____________ 

_____________________________ ____________ 

_____________________________ ____________ 

_____________________________ ____________ 

_____________________________ ____________ 

_____________________________ ____________ 

_____________________________ ____________ 

_____________________________ ____________ 

_____________________________ ____________ 

_____________________________ ____________ 

_____________________________ ____________ 

_____________________________ ____________ 

_____________________________ ____________ 

E. Income/Payments Received

List all income or other payments received from any source in the last 12 months by you, or by any other person

or entity if you have any right, power or authority to control or enjoy the use of the money or property received

by such other person or entity. Identify the source, the recipient and the amount of payment, including but not

limited to the items listed below.

Description/Purpose Source	 Amount 

1. Salary/Wages

2. Commissions/Advances

3. Bonuses

4. Dividends

5. Interest

6. Distributions of Capital

7. Annuity, Pension Payments

8. Rents/Royalties (net)

9. Sales of Assets (net)

10. Repayment of Loans

11. Alimony/Child Support

12. Gifts over $1,000

13. Payments by Others on Your Behalf

(see section I below)

14. Other (itemize):

15. Total Income/Receipts

16. If you anticipate unusual income in the coming 12 months, please explain.

4


Last name _______________________

 

 

	 	 	

 

 

 

	 	 	 	 	 	

	 	 	

_____________________________

_____________________________

_____________________________

_____________________________

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

________________ 

________________ 

________________ 

________________ 

_________________ 

_________________ 

_________________ 

_________________ 

_________________ 

_________________ 

_________________ 

_________________ 

_________________ 

_________________ 

_________________ 

F. Expenses/Disbursements

List all your expenditures for the past 12 months, including but not limited to the items listed below. Identify the

purpose and the amount of each expenditure.

Description	 Amount 

1. Mortgage/Rent

2. Food

3. Utilities

4. Payments on Loans

5. Real Estate Taxes

6. Insurance Premiums

7. Medical Expenses

8. Automobile Expenses

9. Alimony/Child Support

10. Income Taxes (federal, state and local)

11. Other Expenses (itemize):

12. Total Expenses/Disbursements

13. If you anticipate unusual expenses in the coming 12 months, please describe them.

G. Asset Schedules

1. For each asset or class of assets included in Section II.B(5-13) with a fair market value greater than $2,000,

describe the asset(s), state the form of ownership (e.g., individual, joint, beneficial interest), provide a fair market

value, and explain how fair market value was determined (e.g., appraisal, comparison, estimate, etc.).

2. List all securities or commodities brokerage accounts and accounts at banks or other financial institutions in your

name, under your control, in which you have or had a beneficial interest, or to which you are or were a signatory

since the date of the first violation alleged against you. For each account, specify the location of the account,

account number, balance and balance date. Please identify all accounts, regardless of their location.

3. List all 401(k) plans, pension plans, Keogh plans, individual retirement accounts, profit sharing plans, thrift plans,

life insurance policies or annuities in which you have an interest, vested or otherwise. For each account, specify

the account name, the location of the account, account number, balance and balance date. For each account state

whether you are permitted to borrow against or make withdrawals from the account.

5


Last name _______________________

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 		 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 		 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

4. Identify the location and account number of all your safe deposit boxes. Include any boxes in which you have

property or papers, whether or not you are the account holder.

5. Identify all patents, trademarks, service marks, royalty agreements, licenses, or other general intangibles in which

you have an interest.

H. Liability Schedules

1. For each liability greater than $2,000 listed in Section II.C., indicate the creditor, the account number, if any; the

date incurred; the original amount of the liability; the length of the obligation; the interest rate; the collateral or

security, if any; the outstanding balance; and the name(s) and address(es) of any other obligee(s). State whether you

are related to or have a personal or social relationship with the creditor, its management or owners.

2. List all credit cards and lines of credit in your name or to which you are a signatory, including the name of the

credit issuer, account number, credit limit, and amount of indebtedness.

3. List all contingent liabilities. Include any notes on which you are a co-maker, guarantor or endorser and all pending

lawsuits in which you are named as a defendant.

I. Schedules of Income, Receipts and Disbursements

1. Disbursements by Others on Your Behalf. List any payments or disbursements having a value of $1,000 or greater

made by any other person or entity to a third party on your behalf since the date of the first violation alleged

against you. Include the amount of the disbursement and the name and address of the person or entity who made

the disbursement. If no such disbursements have been made, please so state.

2. Fringe Benefits. List any fringe benefits, such as the lease of an automobile, currently provided by your employer.

3. Asset Transfers by You. List any assets or property with a cost or fair market value of $2,000 or more that you

transferred or otherwise disposed of since the date of the first violation alleged against you. State the value of the

asset, the consideration received, and your relationship with the transferee. If no such transfers have been made,

please so state.

4. Additional Deposits by You. Identify any financial institution accounts (other than those identified in section G.2.

above) in which you have deposited more than $2,000 since the date of the first violation alleged against you. If no

such deposits have been made, please so state.

5. Trusts and Inheritances Already Vested. Describe any vested interest in a trust or will pursuant to which you are

receiving or will receive a devise, bequest, other inheritance or distribution.

6. Current and Prior Business Relations. List any sole proprietorships, joint ventures, corporations or other business

enterprises in which you are now or have been a principal, holder of 10 percent or more of the issued stock, officer,

director, manager or chief operating officer at any time since the date of the first violation alleged against you.

6


Last name _______________________

______________________________ ___________ _________ 

	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 		 	 	 	

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	

 

 

( ) ___________________
 

( ) ___________________
 

( ) ___________________
 

(	 )	 ___________________
 

J. Personal Information

Current residence: _______________________________ _______________________ 

Street	 Unit

City	 State	 Zip Code

Current phone number(s): Home 

Business 

Car 

Other	

Social Security Number:	 ____________________ 

List any other names (including a maiden name) you have used. 

If currently married, please state your spouse’s name, age and social security number, whether or not he or she resides

with you, and the date of your marriage. 

If you have previously been married, please state the name of your former spouse(s) and the date of your marriage(s). 

If the date of a marriage was after the date of the first violation alleged against you, include your former spouse’s social

security number and last known address. 

Identify all dependents. For each, please state his or her age, social security number, and whether or not he or she 

resides with you. 

Identify any other members of your household. For each, please state his or her age and relationship to you. 

K. Attachments

1. Attach any federal tax returns filed by you (including personal, trust, or business returns) for the year of the first

violation alleged against you and all subsequent years.

2. Attach any federal gift tax returns filed by you for the year of the first violation alleged against you and all

subsequent years.

3. Attach any financial statement that you prepared for any purpose (e.g., a financial statement provided to a bank to

secure a loan) in the year of the first violation alleged against you and all subsequent years.

4. If you are a trustee, executor or administrator, attach a copy of the instrument appointing you as such.

5. List of Attachments Submitted With This Form:

Please list all financial statements, tax returns and other materials submitted with this form. Do not submit

originals. Make sure all copies are legible. Illegible copies do not satisfy the requirements for filing your

financial disclosure information.

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____________________________________________ ______________________ 		

	 	 	

___________________________ 

L. Declarations and Signature

I, _____________________________ , hereby declare under penalty of perjury that I have examined the 

information given in this statement and attached hereto and, to the best of my knowledge and belief, it is true, 

correct, and complete. I further declare that I have no assets, owned either directly or indirectly, or income of 

any nature other than as shown in, or attached to, this statement. I understand that any material misstatements or 

omissions made by me herein, or in any attachments hereto, may constitute criminal violations, punishable under 

18 U.S.C. 1001 or other statutes.

The Securities and Exchange Commission and any of its staff are authorized to obtain any such information from

credit bureaus, financial institutions or any other source as may be needed to verify the statements made on this

form. 

The statements herein and attached hereto represent my financial condition as of ______________________ .

 Date 

Signature	 Date

Sworn before me this _____ day of ________________, 20___ . 

[Seal]

Notary Public 

My commission expires on ________________

 Date 

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