Form SBSE-W OMB Approval 

OMB Number: 3235-0696 

Expires: April 30, 2022

Estimated average burden 

per response: 1 hour 

Request for Withdrawal from 

Registration as a 

Security-based Swap Dealer or 

Major Security-based Swap 

Participant 

Persons who respond to the collection of information contained SEC 2928 (1/16) in this form are not required to respond unless the form displays 

a currently valid OMB control number. 
 

 

 

FORM SBSE-W INSTRUCTIONS 

A. GENERAL INSTRUCTIONS 

1. Security-based swap dealers and major security-based swap participants (collectively “SBS Entities”) must file Form SBSE-W 

to withdraw their registration from the Securities and Exchange Commission (“SEC”). 

2. All questions must be answered and all fields requiring a response must be complete before the filing is accepted. 

3. The registrant must file Form SBSE-W through the EDGAR system, and must utilize the EDGAR Filer Manual (as defined in 

17 CFR 232. 11) to file and amend Form SBSE-W electronically to assure the timely acceptance and processing of those 

filings. Prior to filing Form SBSE-W, amend Form SBSE, Form SBSE-A, or Form SBSE-BD, as applicable, in accordance with 

Rule 15Fb2-3 [17 CFR 240.15Fb2-3], to update any incomplete or inaccurate information. 

4. A paper copy of this Form SBSE-W with the original manual signature(s) must be retained by the security-based swap dealer 

or major security-based swap participant filing the Form SBSE-W and be made available for inspection upon a regulatory 

request. A paper copy of the initial Form SBSE, Form SBSE-A, or Form SBSE-BD filing, as appropriate, and amendments to 

any Disclosure Reporting Pages (DRPs) also must be retained by the security-based swap dealer and major security-based 

swap participant filing the Form SBSE-W. 

The mailing address for questions and correspondence is: 

The Securities and Exchange Commission
 

Washington, DC 20549
 

EXPLANATION OF TERMS
 (The following terms are italicized throughout this form.)
 

The term INVESTIGATION includes: (a) grand jury investigations, (b) U.S. Securities and Exchange Commission investigations 

after the “Wells” notice has been given, (c) formal investigations by a self-regulatory organization or, (d) actions or procedures 

designated as investigations by jurisdictions. The term investigation does not include subpoenas, preliminary or routine regulatory 

inquiries or requests for information, deficiency letters, “blue sheet” requests or other trading questionnaires, or examinations. 

The term INVESTMENT-RELATED pertains 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, 

savings association, credit union, insurance company, or insurance agency). 

FEDERAL INFORMATION LAW AND REQUIREMENTS – SEC’s Colllection of Information 

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 it is necessary or appropriate in the public interest or for the protection of 

investors to permit the security-based swap dealer or major security-based swap participant to withdraw its registration. The 

Commission maintains a file of the information on this Form and will make the information 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. 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORM SBSE-W Request for Withdrawal from Registration as a 

Security-based Swap Dealer or Major Security-based 

Swap Participant 

Official Use 

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

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

NOTE: Prior to filing a notice of withdrawal from registration on Form SBSE-W, an entity must update any incomplete or 

inaccurate information contained on Form SBSE, Form SBSE-A, or Form SBSE-BD, as appropriate [17 CFR 15Fb3-

2(a)]. 

1. A. Full name of Security-based Swap Dealer or Major Security-based Swap Participant: B. IRS Emp. Ident. No.: 

C. Name under which business is conducted, if different: D. Firm SEC, NFA, and/or CRD No.: 

E. Firm main address: Number and Street City State/Country Zip+4/Postal Code 

F. Mailing address, if different: Number and Street City G. Area Code / Telephone No.: 

2. Withdrawing from Registration as a: [ ] Security-based Swap Dealer [ ] Major Security-based Swap Participant 

3. Date firm ceased business: MM DD YY 

/ / 

4. Reason security-based swap dealer or major security-based swap participant is seeking to withdraw from SEC registration: 

[ ] Winding down all business 

[ ] No longer doing security-based swap business in U.S. 

[ ] Have effected less security-based swap business for 

previous four quarters and no longer fit definition of major 

security-based swap participant 

[ ] Ceasing business as a security-based swap dealer 

[ ] Ceasing business as a major security-based swap 

participant 

[ ] Other (describe): 

________________________________________________ 

5. 

Yes No 

Does the security-based swap dealer or major security-based swap participant hold any segregated counterparty collateral? [ ] [ ] 

A. Number of counterparties whose collateral is held: 

B. Amount of money held as collateral: $ 

C. Market value of securities held as collateral: $ 

D. Describe arrangements made for return of collateral:

 __________________________________________________________________________________________________ 

6. Is the security-based swap dealer or major security-based swap 

participant currently the subject of or named in any investment-related:

 yes no 

- investigation [ ] [ ] 

- customer-initiated complaint [ ] [ ] 

- private civil litigation [ ] [ ] 

7. Name and Address of the Person who will have Custody of Books and Records: Area Code / Telephone No.: 

Address where the Books and Records will be Located, if Different: Number and Street City State/Country ZIP + 4/Postal Code 

EXECUTION: The undersigned certifies that he/she has executed this form on behalf of, and with the authority of, the security-based swap dealer or securitybased swap participant, and that all information herein, including any attachments hereto, is accurate, complete, and current. The undersigned and security-based 

swap dealer or major security-based swap participant further certify that all the information previously submitted on Form SBSE, Form SBSE-A, or Form SBSE-BD, 

as appropriate, is accurate and complete as of this date, and that the security-based swap dealer’s or major security-based swap participant’s books and records 

will be preserved and available for inspection as required by law. 

Date (MM/DD/YYYY) Name 

By: 

Signature Print Name and Title