UNITED STATES

SECURITIES AND EXCHANGE COMMISSION

Washington, D.C. 20549

ANNUAL REPORTS 

FORM X-17A-5 

PART III

FACING PAGE

Information Required Pursuant to Rules 17a-5, 17a-12, and 18a-7 under the Securities Exchange Act of 1934

FILING FOR THE PERIOD BEGINNING _____________________ AND ENDING ______________________

MM/DD/YY MM/DD/YY

A. REGISTRANT IDENTIFICATION

NAME OF FIRM: _______________________________________________________________________

TYPE OF REGISTRANT (check all applicable boxes): 

☐ Broker-dealer ☐ Security-based swap dealer ☐ Major security-based swap participant

☐ Check here if respondent is also an OTC derivatives dealer

ADDRESS OF PRINCIPAL PLACE OF BUSINESS: (Do not use a P.O. box no.)

_____________________________________________________________________________________

(No. and Street)

_____________________________________________________________________________________

(City) (State) (Zip Code)

PERSON TO CONTACT WITH REGARD TO THIS FILING

_____________________________________________________________________________________

(Name) (Area Code – Telephone Number) (Email Address)

B. ACCOUNTANT IDENTIFICATION

INDEPENDENT PUBLIC ACCOUNTANT whose reports are contained in this filing*

_____________________________________________________________________________________

(Name – if individual, state last, first, and middle name)

_____________________________________________________________________________________

(Address) (City) (State) (Zip Code)

_____________________________________________________________________________________

(Date of Registration with PCAOB)(if applicable) (PCAOB Registration Number, if applicable) 

FOR OFFICIAL USE ONLY

* Claims for exemption from the requirement that the annual reports be covered by the reports of an independent public

accountant must be supported by a statement of facts and circumstances relied on as the basis of the exemption. See 17

CFR 240.17a-5(e)(1)(ii), if applicable.

Persons who are to 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.

OMB APPROVAL

OMB Number: 3235-0123

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hours per response: 12

SEC FILE NUMBER 
OATH OR AFFIRMATION

I, ___________________________________________, swear (or affirm) that, to the best of my knowledge and belief, the 

financial report pertaining to the firm of ____________________________________________________________, as of 

______________________________, 2_____, is true and correct. I further swear (or affirm) that neither the company nor any 

partner, officer, director, or equivalent person, as the case may be, has any proprietary interest in any account classified solely 

as that of a customer. 

Signature: 

__________________________________________ 

Title: 

__________________________________________ 

______________________________

Notary Public

This filing** contains (check all applicable boxes):

☐ (a) Statement of financial condition.

☐ (b) Notes to consolidated statement of financial condition.

☐ (c) Statement of income (loss) or, if there is other comprehensive income in the period(s) presented, a statement of 

comprehensive income (as defined in § 210.1-02 of Regulation S-X). 

☐ (d) Statement of cash flows.

☐ (e) Statement of changes in stockholders’ or partners’ or sole proprietor’s equity.

☐ (f) Statement of changes in liabilities subordinated to claims of creditors.

☐ (g) Notes to consolidated financial statements.

☐ (h) Computation of net capital under 17 CFR 240.15c3-1 or 17 CFR 240.18a-1, as applicable.

☐ (i) Computation of tangible net worth under 17 CFR 240.18a-2.

☐ (j) Computation for determination of customer reserve requirements pursuant to Exhibit A to 17 CFR 240.15c3-3.

☐ (k) Computation for determination of security-based swap reserve requirements pursuant to Exhibit B to 17 CFR 240.15c3-3 or 

Exhibit A to 17 CFR 240.18a-4, as applicable.

☐ (l) Computation for Determination of PAB Requirements under Exhibit A to § 240.15c3-3. 

☐ (m) Information relating to possession or control requirements for customers under 17 CFR 240.15c3-3.

☐ (n) Information relating to possession or control requirements for security-based swap customers under 17 CFR

240.15c3-3(p)(2) or 17 CFR 240.18a-4, as applicable.

☐ (o) Reconciliations, including appropriate explanations, of the FOCUS Report with computation of net capital or tangible net 

worth under 17 CFR 240.15c3-1, 17 CFR 240.18a-1, or 17 CFR 240.18a-2, as applicable, and the reserve requirements under 17 

CFR 240.15c3-3 or 17 CFR 240.18a-4, as applicable, if material differences exist, or a statement that no material differences 

exist.

☐ (p) Summary of financial data for subsidiaries not consolidated in the statement of financial condition.

☐ (q) Oath or affirmation in accordance with 17 CFR 240.17a-5, 17 CFR 240.17a-12, or 17 CFR 240.18a-7, as applicable. 

☐ (r) Compliance report in accordance with 17 CFR 240.17a-5 or 17 CFR 240.18a-7, as applicable.

☐ (s) Exemption report in accordance with 17 CFR 240.17a-5 or 17 CFR 240.18a-7, as applicable.

☐ (t) Independent public accountant’s report based on an examination of the statement of financial condition. 

☐ (u) Independent public accountant’s report based on an examination of the financial report or financial statements under 17 

CFR 240.17a-5, 17 CFR 240.18a-7, or 17 CFR 240.17a-12, as applicable.

☐ (v) Independent public accountant’s report based on an examination of certain statements in the compliance report under 17 

CFR 240.17a-5 or 17 CFR 240.18a-7, as applicable.

☐ (w) Independent public accountant’s report based on a review of the exemption report under 17 CFR 240.17a-5 or 17 

CFR 240.18a-7, as applicable.

☐ (x) Supplemental reports on applying agreed-upon procedures, in accordance with 17 CFR 240.15c3-1e or 17 CFR 240.17a-12, 

as applicable.

☐ (y) Report describing any material inadequacies found to exist or found to have existed since the date of the previous audit, or 

a statement that no material inadequacies exist, under 17 CFR 240.17a-12(k).

☐ (z) Other: _______________________________________________________________________________________________

**To request confidential treatment of certain portions of this filing, see 17 CFR 240.17a-5(e)(3) or 17 CFR 240.18a-7(d)(2), as 

applicable.