Form SBSE OMB Approval 

OMB Number: 3235-0696 

Expires:. April 30, 2022

Estimated average burden hours 

per response: 42 hours

per amendment: 1 hour

Application for 

Registration of Security-based 

Swap Dealers and Major Securitybased Swap Participants 

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 2924 (9/19)
 

 

 

FORM SBSE INSTRUCTIONS 

A. GENERAL INSTRUCTIONS

1. FORM - Form SBSE is the Application for Registration as either a Security-based Swap Dealer or Major Securitybased Swap Participant (collectively, “SBS Entities”). SBS Entities that are not registered or registering with the

Commission as broker-dealers nor registered or registering with the Commodity Futures Trading Commission

(“CFTC”) as a swap dealer or major swap participant must file this form to register with the Securities and

Exchange Commission. An applicant must also file Schedules A, B, D, E, and F, as appropriate.

2. ELECTRONIC FILING – The applicant must file Form SBSE through the EDGAR system, and must utilize the

EDGAR Filer Manual (as defined in 17 CFR 232. 11) to file and amend Form SBSE electronically to assure the

timely acceptance and processing of those filings.

3. UPDATING - By law, the applicant must promptly update Form SBSE 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 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.

5. 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 requirements 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. Sections 1-17 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 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 screens.

e. A paper copy, with original signatures, of the initial Form SBSE 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 the applicant or control affiliate that

relates to the occurrence of an event reportable under Item 14 must be provided on the applicant’s

appropriate DRP.

3. DIRECT AND INDIRECT OWNERS - Amend the Direct Owners and Executive Officers screen and the

Indirect Owners screen when changes in ownership occur.

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.)
 

1. GENERAL

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.

STATE – Any state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, the U.S. Virgin

Islands, any other territory of the United States, or any subdivision or regulatory body thereof.

PERSON - An individual, partnership, corporation, trust, or other organization.

SELF-REGULATORY ORGANIZATION (SRO) - Any national securities or futures exchange, registered securities or

futures association, registered clearing agency, or derivatives clearing organization.

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 participant that ceases its security-based swap activities. [See Exchange Act Rule 15Fb2-5 (17

CFR 240.15Fb2-5]

UNIQUE IDENTIFICATION CODE or UIC – For purposes of Form SBSE, 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))].

2. FOR THE PURPOSE OF ITEM 14 AND THE CORRESPONDING DISCLOSURE REPORTING PAGES (DRPs)

CHARGED - Being accused of a crime in a formal complaint, information, or indictment (or equivalent formal charge).

CONTROL AFFILIATE – A person named in Items 10 or 11 as a control person or any other individual or

organization that directly or indirectly controls, is under common control with, or is controlled by, the applicant,

including any current employee of the applicant except one performing only clerical, administrative, support or similar

functions, or who, regardless of title, performs no executive duties or has no senior policy making authority.

ENJOINED – Includes being subject to a mandatory injunction, prohibitory injunction, preliminary injunction, or a

temporary restraining order.

FELONY – For jurisdictions that do not differentiate between a felony and a misdemeanor, a felony is an offense

punishable by a sentence of at least one year imprisonment and/or a fine of at least $1,000. The term also includes a

general court martial.

FOUND – Includes adverse final actions, including consent decrees in which the respondent has neither admitted nor

denied the findings, but does not include agreements, deficiency letters, examination reports, memoranda of

understanding, letters of caution, admonishments, and similar informal resolutions of matters.

INVESTMENT OR INVESTMENT-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).

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

reasonably to supervise another in doing an act.
MINOR RULE VIOLATION – A violation of a self-regulatory organization rule that has been designated as “minor” 

pursuant to a plan approved by the SEC or CFTC. A rule violation may be designated as “minor” under a plan if the 

sanction imposed consists of a fine of $2,500 or less, and if the sanctioned person does not contest the fine. (Check 

with the appropriate self-regulatory organization to determine if a particular rule violation has been designated as 

“minor” for these purposes). 

MISDEMEANOR – For jurisdictions that do not differentiate between a felony and a misdemeanor, a misdemeanor is 

an offense punishable by a sentence of less than one year imprisonment and/or a fine of less than $1,000. The term 

also includes a special court martial. 

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). 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Official Use Official 

Use FORM SBSE Only 

Page 1 

(Execution Page) 

Uniform Application for Security-based Swap 

Dealer and Major Security-based Swap Participant 

Registration

 Date:__________ SEC Filer No: _________ 

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

WARNING: 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 may result in disciplinary, administrative, injunctive or criminal action. 

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. Tax Identification No.: Applicant’s UIC # (if any): Applicant’s CIK # (if any): 

C. (1) The business name under which the applicant primarily conducts business, if different from 1A. 

(2) List on Schedule D, Page 1, Section I any other name by which the applicant conducts business and where it

is used.

D. If this filing makes a name change on behalf of an applicant, enter the new name and specify whether the change is to the

[ ] applicant’s name (1A) or [ ] business name (1C):

Please check above.

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

Number and Street 1: Number and Street 2: 

City:	 State: Country: Zip/Postal Code: 

Other business locations must be reported on Schedule E. Security-based swap dealers and major security-based swap 

participants that do not reside in the United States of America shall designate a U.S. agent for service of process on Schedule F. 

F. Mailing Address, if different:

Number and Street 1: Number and Street 2: 

City:	 State: Country: Zip/Postal Code: 

G. Business Telephone Number:

H Website/URL:

I. Contact Employee:

Name: Title:

 Telephone Number: Email Address: 

J. 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 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORM SBSE 

Page 2 

Applicant Name: _____________________________________ 

Date:__________ SEC Filer 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. Is the applicant subject to regulation by a prudential regulator, as defined in Section 1a(39) of the Commodity Exchange 

Act. [ ] Yes [ ] No 

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

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. A. Indicate legal status of the applicant: 

[ ] Corporation [ ] Limited Liability Company [ ] Other (specify)
 

[ ] Partnership 

Month applicant's fiscal year ends: B. 

Indicate date and place applicant obtained its legal status (i.e., state or country where incorporated, where C. partnership agreement was filed, or where applicant entity was formed):
 

State of formation: Country of formation: Date of formation: MM/DD/YYYY 

Schedule A and, if applicable, Schedule B must be completed as part of all initial applications. 

9. Is the applicant at the time of this filing succeeding to the business of a currently registered SBS Entity? YES NO 

If “Yes,” complete appropriate items on Schedule D, Page 1, Section III. [ ] [ ] 

10. Does the applicant hold or maintain any funds or securities to collateralize counterparty transactions? [ ] [ ] 
 

 

 

 

 

 

 

 

 

 

 

 

 

FORM SBSE 

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Applicant Name: _____________________________________ 

Date:__________ SEC Filer No: __________ 

Official Use Official 

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Only 

11. 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 any other person, firm or organization executes, trades, custodies, clears or settles on

behalf of the applicant (including any SRO or swap execution facility in which the applicant is a

member)?

If “Yes” to any part of Item 11, complete appropriate items on Schedule D, Page 1, Section IV.

YES NO 

[ ] [ ]

 [ ] [ ] 

12. Does any person directly or indirectly:

A. Control the management or policies of the applicant through agreement or otherwise?

B. Wholly or partially finance the business of the applicant?

Do not answer “Yes” to 12B 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” to any part of Item 12, complete appropriate items on Schedule D, Page 1, Section IV.

 [ ] [ ]

 [ ] [ ] 

13. A. Directly or indirectly, does the applicant control, is the applicant controlled by, or is the applicant under

common control with, any partnership, corporation, or other organization that is engaged in the 

securities or investment advisory business? 

If “Yes” to item 13A, complete appropriate items on Schedule D, Page 2, Section V.

B. Directly or indirectly, is applicant controlled by any bank holding company or does applicant control, is

applicant controlled by, or is applicant under common control with any bank (as defined in 15 U.S.C. 

78c(a)(6)) or any foreign bank? 

If “Yes” to item 13B, complete appropriate items on Schedule D, Page 3, Section VI.

 [ ] [ ]

 [ ] [ ] 

14. Use the appropriate DRP for providing details to “yes” answers to the questions in Item 14. Refer to the

Explanation of Terms section of Form SBSE Instructions for explanations of italicized terms.

CRIMINAL DISCLOSURE

A. In the past ten years has the applicant or a control affiliate:

(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 applicant or a control affiliate:

(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 14B(1)?

[ ] [ ] 

[ ] [ ]

 [ ] [ ] 

[ ] [ ] 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORM SBSE 

Page 4 

Applicant Name: _____________________________________ 

Date:__________ SEC Filer No: __________ 

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Only 

REGULATORY ACTION DISCLOSURE

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

ever:

(1) Found the applicant or a control affiliate to have made a false statement or omission?

(2) Found the applicant or a control affiliate to have been involved in a violation of its regulations or

statutes?

(3) Found the applicant or a control affiliate 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 applicant or a control affiliate in connection with investment-related

activity?

(5) Imposed a civil money penalty on the applicant or a control affiliate, or ordered the applicant or a

control affiliate to cease and desist from any activity?

YES NO 

[ ] [ ] 

[ ] [ ] 

[ ] [ ] 

[ ] [ ] 

[ ] [ ]

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

authority:

(1) Ever found the applicant or a control affiliate to have made a false statement or omission or been

dishonest, unfair, or unethical?

(2) Ever found the applicant or a control affiliate to have been involved in a violation of investmentrelated regulations or statutes?

(3) Ever found the applicant or a control affiliate 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 applicant or a control affiliate in connection with

an investment-related activity?

(5) Ever denied, suspended, or revoked the applicant’s or a control affiliate’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:

[ ] [ ] 

[ ] [ ] 

[ ] [ ] 

[ ] [ ] 

[ ] [ ]

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

(2) found the applicant or a control affiliate 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 applicant or a control affiliate to have been the cause of an investment-related business [ ] [ ] 

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

(4) Disciplined the applicant or a control affiliate by expelling or suspending it from membership, barring [ ] [ ]

or suspending its association with other members, or otherwise restricting its activities? 

F. Has the applicant’s or a control affiliate’s authorization to act as an attorney, accountant, or federal [ ] [ ]

contractor ever been revoked or suspended?

G. Is the applicant or a control affiliate now the subject of any regulatory proceeding that could result in a [ ] [ ] 

“yes” answer to any part of 14C, D, or E? 

CIVIL JUDICIAL DISCLOSURE

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

(a) In the past ten years, enjoined the applicant or a control affiliate in connection with any

investment-related activity?

(b) Ever found that the applicant or a control affiliate was involved in a violation of investmentrelated statutes or regulations? 

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

brought against the applicant or control affiliate by a state or foreign financial regulatory 

authority? 

(2) Is the applicant or a control affiliate now the subject of any civil judicial proceeding that could result

in a “yes” answer to any part of 14H(1)?

[ ] [ ]

 [ ] [ ]

 [ ] [ ] 

[ ] [ ] 
 

 

 

 

 

 

 

FORM SBSE 

Page 5 

Applicant Name: _____________________________________ 

Date:__________ SEC Filer No: __________ 

Official Use Official 

Use 

Only 

FINANCIAL

DISCLOSURE 

I. In the past ten years has the applicant or a control affiliate ever been a securities firm or a futures firm,

or a control affiliate of a securities firm or a futures 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?

YES NO 

[ ] [ ] 

[ ] [ ] 

15. Is the applicant registered with the Commission as an investment adviser or municipal securities

advisor or with the CFTC as a commodity trading adviser?

If “yes,” provide all unique identification numbers assigned to the firm relating to this business on

Schedule D, Page 1, Section II.

[ ] [ ] 

16. A. Does applicant effect transactions in commodity futures, commodities or commodity options as a broker

for others or as a dealer for its own account? 

If “yes,” provide all unique identification numbers assigned to the firm relating to this business on 

Schedule D, Page 1, Section II. 

B. Does applicant engage in any other investment-related, non-securities business?

If “yes,” provide all unique identification numbers assigned to the firm relating to this business and

describe each other business briefly on Schedule D, Page 1, Section II.

[ ] [ ] 

[ ] [ ] 

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

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

[ ] [ ] 
 

 

 

 

 

 

 

 

 

 

 

Schedule A of FORM 

SBSE 

DIRECT OWNERS AND 

EXECUTIVE OFFICERS 

(Answer for Form SBSE Item 8) 

Applicant Name: ___________________________________ 

Date:__________ SEC Filer No: __________ 

Official Use 

1. Use Schedule A to provide information on the direct owners and executive officers of the applicant. Use Schedule B to provide

information on indirect owners. Complete each column.

2. List below the names of:

(a) Each Chief Executive Officer, Chief Financial Officer, Chief Operations Officer, Chief Legal Officer, Chief Compliance Officer,

Director, and individuals with similar status or function;

(b) In the case of an applicant that is a corporation, each shareholder that directly owns 5% or more of a class of a voting security of the

applicant, unless the applicant is a public reporting company (a company subject to Sections 12 or 15(d) of the Securities Exchange

Act of 1934).

Direct owners include any person that owns, beneficially owns, has the right to vote, or has the power to sell or direct the sale of, 5%

or more of a class of a voting security of the applicant. For purposes of this Schedule, a person beneficially owns any securities (i)

owned by his/her child, stepchild, grandchild, parent, stepparent, grandparent, spouse, sibling, mother-in-law, father-in-law, son-inlaw, daughter-in-law, brother-in-law, or sister-in-law, sharing the same residence, or (ii) that he/she has the right to acquire, within 60

days, through the exercise of any option, warrant or right to purchase the security.

(c) In the case of an applicant that is a partnership, all general partners, and those limited and special partners that have the right to

receive upon dissolution, or have contributed, 5% or more of the partnership’s capital; and

(d) In the case of a trust that directly owns 5% or more of a class of a voting security of the applicant, or that has the right to receive

upon dissolution, or has contributed, 5% or more of the applicant’s capital, the trust and each trustee.

(e) In the case of an applicant that is a Limited Liability Company (“LLC”), (i) those members that have the right to receive upon

dissolution, or have contributed, 5% or more of the LLC’s capital, and (ii) if managed by elected managers, all elected managers.

3. Are there any indirect owners of the applicant required to be reported on Schedule B? [ ] Yes [ ] No

4. In the “DE/FE/I” column, enter “DE” if the owner is a domestic entity, or enter “FE” if owner is an entity incorporated or domiciled in a

foreign country, or enter “I” if the owner is an individual.

5. 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).

6. 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 

7. (a) In the “Control Person” column, enter “Yes” if person has control as defined in the instructions to this form, and enter “No” if the

person does not have control. Note that under this definition most executive officers and all 25% owners, general partners, and 

trustees would be “control persons”. 

(b) In the “PR “ column, enter “PR” if the owner is a public reporting company under Sections 12 or 15(d) of the Securities Exchange Act

of 1934.

FULL LEGAL NAME 

(Individuals: Last Name, First Name, Middle Name) 

DE/FE/I Title or Status Date Title or 

Status Acquired 

Ownership

 Code 

Control 

Person 

CRD and/or IARD 

No. and/or foreign 

business No. If 

None, IRS Tax No. 

UIC, if any. Official 

Use 

Only MM YYYY PR 

For individuals 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): 

For individuals 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): 

For individuals 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) 

For individuals 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): 
 

 

 

 

 

Schedule B of FORM 

SBSE 

INDIRECT OWNERS 

(Answer for Form SBSE Item 8) 

Applicant Name: _________________________________ 

Date:__________ SEC Filer No: __________ 

Official Use 

1. Use Schedule B to provide information on the indirect owners of the applicant. Use Schedule A to provide information

on direct owners. Complete each column.

2. With respect to each owner listed on Schedule A, (except individual owners), list below:

(a) In the case of an owner that is a corporation, each of its shareholders that beneficially owns, has the right to vote, or

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

For purposes of this Schedule, a person beneficially owns any securities (i) owned by his/her child, stepchild,

grandchild, parent, stepparent, grandparent, spouse, sibling, mother-in-law, father-in-law, son-in-law, daughter-inlaw, brother-in-law, or sister-in-law, sharing the same residence, or (ii) that he/she has the right to acquire, within 60

days, through the exercise of any option, warrant or right to purchase the security.

(b) In the case of an owner that is a partnership, all general partners, and those limited and special partners that have

the right to receive upon dissolution, or have contributed, 25% or more of the partnership’s capital; and

(c) In the case of an owner that is a trust, the trust and each trustee.

(d) In the case of an owner that is a Limited Liability Company (“LLC”), (i) those members that have the right to receive

upon dissolution, or have contributed, 25% or more of the LLC’s capital, and (ii) if managed by elected managers, all

elected managers.

3. Continue up the chain of ownership listing all 25% owners at each level. Once a public company (a company subject to

Sections 12 or 15(d) of the Securities Exchange Act of 1934) is reached, no ownership information further up the chain

of ownership need be given.

4. In the “DE/FE/I” column, enter “DE” if the owner is a domestic entity, or enter “FE” if owner is an entity incorporated or

domiciled in a foreign country, or enter “I” if the owner is an individual.

5. Complete the “Status” column by status as partner, trustee, shareholder, etc., and if shareholder, class of securities

owned (if more than one is issued).

6. Ownership Codes are:

C - 25% but less than 50% D - 50% but less than 75% E - 75% or more F - Other General Partners

7. (a) In the “Control Person” column, enter “Yes” if person has control as defined in the instructions to this form, and enter

“No” if the person does not have control. Note that under this definition most executive officers and all 25% owners, 

general partners, and trustees would be “control persons”. 

(b) In the “PR” column, enter “PR” if the owner is a public reporting company under Sections 12 or 15(d) of the

Securities Exchange Act of 1934.

FULL LEGAL NAME 

(Individuals: Last Name, First Name, Middle 

Name) 

DE/FE/I Entity in Which Interest 

is Owned 

Status Date Title or 

Status Acquired 

Ownership

 Code 

Control 

Person 

CRD and/or IARD 

No. and/or foreign 

business No. If 

None, IRS Tax No. 

UIC, if any. Official 

Use 

Only MM YYYY PR 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Schedule D of FORM 

SBSE 

Page 1 

Applicant Name: _____________________________________ 

Date:__________ SEC Filer No: __________ 

Official Use Official 

Use 

Only 

Use Schedule D Page 1 to report details for items listed below. 

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

Section I Other Business Names 

(Check if applicable) [ ] Item 1C(2) 

List each of the “other” names and the state(s) or country(ies) in which they are used. 

1. Name State/Country 2. Name State/Country 

3. Name State/Country 4. Name State/Country 

Section II Other Business 

(Check if applicable) [ ] Item 15 [ ] Item 16A [ ] Item 16B 

Applicant must complete a separate Schedule D Page 1 for each affirmative response in this section. 

Unique Identification Number(s): Assigning Regulator(s)/Entity(s): 

Briefly describe any other investment-related, non-securities business. Use reverse side of this sheet for additional comments if necessary. 

Section III Successions 

(Check if applicable) [ ] Item 9 

Date of Succession MM DD YYYY 

/ / 

Name of Predecessor

IRS Employer Number (if any) SEC File Number (if any) UIC 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 Record Maintenance Arrangements / Business Arrangements / Control Persons / Financings 

(Check one) [ ] Item 11A [ ] Item 11B [ ] Item 12A [ ] Item 12B 

Applicant must complete a separate Schedule D 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, foreign business No., 

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 11A); the nature of the execution, trading, custody, clearing or 

settlement arrangement (ITEM 11B);the nature of the control or agreement (ITEM 12A); or the method and amount of financing (ITEM 12B). Use reverse 

side of this sheet for additional comments if necessary. 

For ITEM 12A 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). 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Schedule D of FORM 

SBSE 

Page 2 

Applicant Name: _____________________________________ 

Date:__________ SEC Filer No: __________ 

Official Use Official 

Use 

Only 

Use this Schedule D Page 2 to report details for Item 13A. Supply details for all partnerships, corporations, 

organizations, institutions and individuals necessary to answer each item completely. Use additional copies of 

Schedule D Page 2 if necessary. 

Use the “Effective Date” box to enter the Month, Day, and Year that the affiliation was effective or the date of the most 

recent change in the affiliation. 

This is an [ ] INITIAL [ ] AMENDED detail filing for Form SBSE Item 13A 

[ ] 13A. Directly or indirectly, does applicant control, is applicant controlled by, or is applicant under common control 

with, any partnership, corporation, or other organization that is engaged in the securities or investment 

advisory business? 

Section V Complete this section for control issues relating to ITEM 13A only. 

The details supplied relate to: 

1. Partnership, Corporation, or Organization Name CRD Number (if any) UIC Number (if any) 

(check only one) 

This Partnership, Corporation, or Organization [ ] controls applicant [ ] is controlled by applicant [ ] is under common control with applicant 

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

 MM DD YYYY 

/ / 

Termination Date

 MM DD YYYY 

/ / 

Is Partnership, Corporation or 

Organization a foreign entity” 

[ ] Yes [ ] No 

If Yes, provide country of domicile 

or incorporation” 

Check “Yes” or “No” for 

activities of this partnership 

Corporation, or organization: ► Securities [ ] Yes [ ] No 

Activities: 

Investment 

Advisory [ ] Yes [ ] No 

Activities: 

Briefly describe the control relationship. Use reverse side of this sheet for additional comments if necessary. 

2. Partnership, Corporation, or Organization Name CRD Number (if any) UIC Number (if any) 

(check only one) 

This Partnership, Corporation, or Organization [ ] controls applicant [ ] is controlled by applicant [ ] is under common control with applicant 

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

 MM DD YYYY 

/ / 

Termination Date

 MM DD YYYY 

/ / 

Is Partnership, Corporation or 

Organization a foreign entity” 

[ ] Yes [ ] No 

If Yes, provide country of domicile 

or incorporation” 

Check “Yes” or “No” for 

activities of this partnership 

Corporation, or organization: ► Securities [ ] Yes [ ] No 

Activities: 

Investment 

Advisory [ ] Yes [ ] No 

Activities: 

Briefly describe the control relationship. Use reverse side of this sheet for additional comments if necessary. 

3. Partnership, Corporation, or Organization Name CRD Number (if any) UIC Number (if any) 

(check only one) 

This Partnership, Corporation, or Organization [ ] controls applicant [ ] is controlled by applicant [ ] is under common control with applicant 

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

 MM DD YYYY 

/ / 

Termination Date

 MM DD YYYY 

/ / 

Is Partnership, Corporation or 

Organization a foreign entity” 

[ ] Yes [ ] No 

If Yes, provide country of domicile 

or incorporation” 

Check “Yes” or “No” for 

activities of this partnership 

Corporation, or organization: ► Securities [ ] Yes [ ] No 

Activities: 

Investment 

Advisory [ ] Yes [ ] No 

Activities: 

Briefly describe the control relationship. Use reverse side of this sheet for additional comments if necessary. 

If applicant has more than 3 organizations to report, complete additional Schedule D Page 2s. 
 

 

 

 

 

 

 

 

 

 

 

Schedule D of FORM 

SBSE 

Page 3 

Applicant Name: _____________________________________ 

Date:__________ SEC Filer No: __________ 

Official Use Official 

Use 

Only 

Use Schedule D Page 3 to report details for Item 13B. Report only new information or changes/updates to previously 

submitted details. Do not report previously submitted information. Supply details for all partnerships, corporations, 

organizations, institutions and individuals necessary to answer each item completely. Use additional copies of Schedule D 

Page 3 if necessary. 

Use the “Effective Date” box to enter the Month, Day, and Year that the affiliation was effective or the date of the most recent 

change in the affiliation. 

This is an [ ] INITIAL [ ] AMENDED detail filing for Form SBSE Item 13B 

[ ] 13B. Directly or indirectly, is applicant controlled by any bank holding company or does applicant control, is applicant 

controlled by, or is applicant under common control with any bank (as defined in 15 U.S.C. 78c(a)(6)) or any foreign bank? 

Section VI Complete this section for control issues relating to ITEM 13B only. 

Provide the details for each organization or institution that controls the applicant, including each organization or institution in 

the applicant’s chain of ownership. The details supplied relate to: 

1. Financial Institution Name CRD Number (if applicable) UIC Number (if any) 

Institution Type (e.g., bank holding company, national bank, state member bank of the 

Federal Reserve System, state non-member bank, savings bank or association, credit 

union, foreign bank.) 

Effective Date MM DD YYYY 

/ / 

Termination Date MM DD YYYY 

/ / 

Business Address (Street, City, State/Country, Zip + 4/Postal Code If foreign, country of domicile or incorporation 

Briefly describe the control relationship. Use reverse side of this sheet for additional comments, if necessary. 

2. Financial Institution Name CRD Number (if applicable) UIC Number (if any) 

Institution Type (e.g., bank holding company, national bank, state member bank of the 

Federal Reserve System, state non-member bank, savings bank or association, credit 

union, foreign bank.) 

Effective Date MM DD YYYY 

/ / 

Termination Date MM DD YYYY 

/ / 

Business Address (Street, City, State/Country, Zip + 4/Postal Code If foreign, country of domicile or incorporation 

Briefly describe the control relationship. Use reverse side of this sheet for additional comments, if necessary. 

3. Financial Institution Name CRD Number (if applicable) UIC Number (if any) 

Institution Type (e.g., bank holding company, national bank, state member bank of the 

Federal Reserve System, state non-member bank, savings bank or association, credit 

union, foreign bank.) 

Effective Date MM DD YYYY 

/ / 

Termination Date MM DD YYYY 

/ / 

Business Address (Street, City, State/Country, Zip + 4/Postal Code If foreign, country of domicile or incorporation 

Briefly describe the control relationship. Use reverse side of this sheet for additional comments, if necessary. 

4. Financial Institution Name CRD Number (if applicable) UIC Number (if any) 

Institution Type (e.g., bank holding company, national bank, state member bank of the 

Federal Reserve System, state non-member bank, savings bank or association, credit 

union, foreign bank.) 

Effective Date MM DD YYYY 

/ / 

Termination Date MM DD YYYY 

/ / 

Business Address (Street, City, State/Country, Zip + 4/Postal Code If foreign, country of domicile or incorporation 

Briefly describe the control relationship. Use reverse side of this sheet for additional comments, if necessary. 

If applicant has more than 4 organizations/institutions to report, complete additional Schedule D page 3s. 
 

 

 

 

 

 

 

Schedule E of FORM 

SBSE 

Page 1 

Applicant Name: _____________________________________ 

Date:__________ SEC Filer No: __________ 

Official Use 

INSTRUCTIONS 

General: Use this schedule to identify other business locations of the applicant. Repeat Items 1-6 for each other business location. Each item 

must be completed unless otherwise noted. Use additional copies of this schedule as necessary. 

Specific: 

Item 1. Specify only one box. Check “Add” when the applicant is filing the initial notice to inform the Commission that it has opened another 

business location, “Delete’’ when the applicant closes another business location, and “Amendment” to indicate any other change to 

previously filed information. 

Item 2. Complete this item for all entries. Provide the date that the other business location was opened (ADD), closed (DELETE), or the 

effective date of the change (AMENDMENT). 

Item 3. Complete this item for all entries. A physical location must be included; post office box designations alone are not sufficient. 

Item 4. Complete this item only when the applicant changes the address of an existing other business location. 

Item 5. If the other business location occupies or shares space on premises within a bank, or other financial institution, enter the name of the 

institution in the space provided. 

Item 6. Complete this item for all entries. Enter the name of the associated person who is responsible for the operations of, and is physically 

at, this location. 

1. Check only one box: [ ] Add [ ] Delete [ ] Amendment 

2. Effective Date: 4. Street: 

3. Street: P.O. Box (if applicable), Suite, Floor: 

P.O. Box (if applicable), Suite, Floor: City, State/Country, Zip Code +4/Postal Code: 

City, State/Country, Zip Code +4/Postal Code: 5. Institution Name: 

6. Responsible Associated Person: 

1. Check only one box: [ ] Add [ ] Delete [ ] Amendment 

2. Effective Date: 4. Street: 

3. Street: P.O. Box (if applicable), Suite, Floor: 

P.O. Box (if applicable), Suite, Floor: City, State/Country, Zip Code +4/Postal Code: 

City, State/Country, Zip Code +4/Postal Code: 5. Institution Name: 

6. Responsible Associated Person: 

1. Check only one box: [ ] Add [ ] Delete [ ] Amendment 

2. Effective Date: 4. Street: 

3. Street: P.O. Box (if applicable), Suite, Floor: 

P.O. Box (if applicable), Suite, Floor: City, State/Country, Zip Code +4/Postal Code: 

City, State/Country, Zip Code +4/Postal Code: 5. Institution Name: 

6. Responsible Associated Person: 
 

 

 

 

 

 

 

 

_______________________________________ ___________________ __________________ 

_______________________________________ ___________________ __________________ 

_______________________________________ ___________________ __________________ 

Schedule F of FORM 

SBSE 

Page 1 

Applicant Name: 

_________________________________ 

Date:__________ SEC Filer 

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 

Section I 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)(1)(ii) or (c)(2) of Exchange Act Rule 15Fb2-4, as appropriate 

[paragraphs (c)(1)(ii) or (c)(2) 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 security-based 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. 
 

 

 

 

 

CRIMINAL DISCLOSURE REPORTING PAGE (SBSE) 

GENERAL INSTRUCTIONS 

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

affirmative responses to Items 14A and 14B of Form SBSE; 

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

14A. In the past ten years has the applicant or a control affiliate: 

[ ] (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? 

14B. In the past ten years has the applicant or a control affiliate: 

[ ] (1) Been convicted of or pled guilty 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 14B(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 control affiliate is an individual or organization registered through the CRD, such control affiliate need only complete 

Part I of the applicant’s appropriate DRP (SBSE). Details of the event must be submitted on the control affiliate’s 

appropriate DRP (BD) or DRP (U-4). If a control affiliate is an individual or 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 control affiliate 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. The person(s) or entity(ies) for whom this DRP (SBSE) is being filed is (are): 

[ ] The Applicant 

[ ] Applicant and one or more control affiliate(s) 

[ ] One or more control affiliate(s) 

If this DRP is being filed for a control affiliate, give the full name of the control affiliate below (for individuals, Last 

name, First name, Middle name). 

If the control affiliate is registered with the CRD, provide the CRD number. If not, indicate “non-registered” by
 

checking the appropriate checkbox.
 

Name of Applicant 

SBSE DRP – CONTROL AFFILIATE 

CRD NUMBER UIC NUMBER (if any) This Control Affiliate is [ ] Firm [ ] Individual 

Registered: [ ] Yes [ ] No 

NAME (For individuals, Last, First, Middle) 

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

associated with the SBS Entity. 

B. If the control affiliate is registered through the CRD, has the control affiliate 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 control affiliate of its obligation to update its CRD records.
 
 

 

 

 

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CRIMINAL DISCLOSURE REPORTING PAGE (SBSE) 

(continuation) 

PART II 

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

organization name, whether or not the organization was an investment-related business and the applicant’s or control 

affiliate’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.) 
 

 

 

 

 

 

 

 

 

 

 

 

REGULATORY ACTION DISCLOSURE REPORTING PAGE (SBSE)
 GENERAL INSTRUCTIONS 

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

responses to Items 14C, 14D, 14E, 14F, or 14G of Form SBSE; 

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

14C. Has the U.S. Securities and Exchange Commission or the Commodity Futures Trading Commission ever: 

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

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

[ ] (3) the applicant or a control affiliate 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 applicant or a control affiliate in connection with investment-related activity? 

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

14D. Has any other federal regulatory agency, state regulatory agency, or foreign financial regulatory authority: 

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

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

[ ] (3) Ever found the applicant or a control affiliate 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 applicant or a control affiliate in connection with an investment-related activity? 

[ ] (5) Ever denied, suspended, or revoked the applicant’s or a control affiliate’s registration or license or otherwise, by order, prevented it from associating with an 

investment-related business or restricted its activities? 

14E. Has any self-regulatory organization or commodities exchange ever: 

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

[ ] (2) found the applicant or a control affiliate 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 applicant or a control affiliate to have been the cause of an investment-related business having its authorization to do business denied, suspended, 

revoked or restricted? 

[ ] (4) Disciplined the applicant or a control affiliate by expelling or suspending it from membership, barring or suspending its association with other members, or 

otherwise restricting its activities? 

14F. [ ] Has the applicant’s or a control affiliate’s authorization to act as an attorney, accountant, or federal contractor ever been revoked or suspended? 

14G. [ ] Is the applicant or a control affiliate now the subject of any regulatory proceeding that could result in a “yes” answer to any part of 14C, 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 14C, 14D, 14E, 14F or 14G. 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 a control affiliate is an individual or organization registered through the CRD, such control affiliate need only complete Part I of the 

applicant’s appropriate DRP (SBSE). Details of the event must be submitted on the control affiliate’s appropriate DRP (BD) or DRP (U-4). If 

a control affiliate is an individual or 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 control affiliate of its obligation to update its CRD records. 

PART I 

A. The person(s) or entity(ies) for whom this DRP is being filed is (are): 

[ ] The Applicant 

[ ] Applicant and one or more control affiliate(s) 

[ ] One or more control affiliate(s) 

If this DRP is being filed for a control affiliate, give the full name of the control affiliate below (for individuals, Last name, 

First name, Middle name).
 

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

the appropriate checkbox.
 

Name of Applicant 

SBSE DRP – CONTROL AFFILIATE 

CRD NUMBER UIC NUMBER (if any) This Control Affiliate is [ ] Firm [ ] Individual 

Registered: [ ] Yes [ ] No 

NAME (For individuals, Last, First, Middle) 

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

associated with the SBS Entity. 

B. If the control affiliate is registered through the CRD, has the control affiliate 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 control affiliate of its obligation to update its CRD records.
 
 

 

 

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REGULATORY ACTION DISCLOSURE REPORTING PAGE (SBSE) 

(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. Control Affiliate 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 [ ] 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: 

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: 
 

 

 

 

 

 

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REGULATORY ACTION DISCLOSURE REPORTING PAGE (SBSE) 

(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 applicant or control affiliate, 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.) 
 

 

 

 

 

 

 

CIVIL JUDICIAL ACTION DISCLOSURE REPORTING PAGE (SBSE)
 GENERAL INSTRUCTIONS 

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

affirmative responses to Items 14H of Form SBSE; 

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

14H(1) Has any domestic or foreign civil judicial court: 

[ ] (a) in the past ten years, enjoined the applicant or a control affiliate in connection with any 

investment-related activity? 

[ ] (b) ever found that the applicant or a control affiliate 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 applicant or a control affiliate by a state or foreign financial regulatory 

authority? 

14H(2) [ ] Is the applicant or a control affiliate now the subject of any civil judicial proceeding that could result 

in a “yes” answer to any part of 14H(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. 

One event may result in more than one affirmative answer to Items 14H. 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 control affiliate is an individual or organization registered through the CRD, such control affiliate need only complete Part I of the 

applicant’s appropriate DRP (SBSE). Details of the event must be submitted on the control affiliate’s appropriate DRP (BD) or DRP (U-4). If 

a control affiliate is an individual or 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 control affiliate of its obligation to update its CRD records. 

PART I 

A. The person(s) or entity(ies) for whom this DRP is being filed is (are): 

[ ] The Applicant 

[ ] Applicant and one or more control affiliate(s) 

[ ] One or more control affiliate(s) 

If this DRP is being filed for a control affiliate, give the full name of the control affiliate below (for individuals, Last name, 

First name, Middle name).
 

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

the appropriate checkbox.
 

Name of Applicant 

DRP SBSE – CONTROL AFFILIATE 

CRD NUMBER UIC NUMBER (if any) This Control Affiliate is [ ] Firm [ ] Individual 

Registered: [ ] Yes [ ] No 

NAME (For individuals, Last, First, Middle) 

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

associated with the SBS Entity. 

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

DRP 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 control affiliate of its obligation to update its CRD records.
 
 

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CIVIL JUDICIAL ACTION DISCLOSURE REPORTING PAGE (SBSE)

(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 

[ ] Annuity(ies) - Variable [ ] Derivative(s) 

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

than CD(s)) [ ] Equity - OTC 

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

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

[ ] Debt – Asset Backed [ ] Futures - Financial 

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

[ ] Debt - Government [ ] Insurance 

Other Product Type: 

[ ] Investment Contract(s) 

[ ] Money Market Fund(s) 

[ ] Mutual Fund(s) 

[ ] No Product 

[ ] Options 

[ ] Penny Stock(s) 

[ ] Unit Investment Trust(s) 

[ ] Other _________________ 

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 judicial 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: 
 

 

 

 

 

 

 

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CIVIL JUDICIAL ACTION DISCLOSURE REPORTING PAGE (SBSE)

(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 applicant or control affiliate, 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) 

GENERAL INSTRUCTIONS 

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

affirmative responses to Questions 14I on Form SBSE; 

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

14l In the past ten years has the applicant or a control affiliate of the applicant 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 control affiliate is an individual or organization registered through CRD, such control affiliate need only complete Part I 

of the applicant’s appropriate DRP (SBSE). Details of the event must be submitted on the control affiliate’s appropriate 

DRP (BD) or DRP (U-4). If a control affiliate is an individual or 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 control affiliate of its obligation to update its CRD records. 

PART I 

A. The person or entity for whom this DRP (SBSE) is being filed is:

[ ] The Applicant

[ ] Applicant and one or more control affiliate(s)

[ ] One or more control affiliate(s)

If this DRP is being filed for a control affiliate, give the full name of the control affiliate below (for individuals, Last

name, First name, Middle name).

If the control affiliate is registered with the CRD, provide the CRD number. If not, indicate “non-registered” by

checking the appropriate checkbox.

Name of Applicant 

BD DRP – CONTROL AFFILIATE 

CRD NUMBER UIC NUMBER (if any) This Control Affiliate is [ ] Firm [ ] Individual 

Registered: [ ] Yes [ ] No 

NAME (For individuals, Last, First, Middle) 

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

associated with the SBS Entity. 

B. If the control affiliate is registered through the CRD, has the control affiliate 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 control affiliate 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: _____________________________________________________________ 

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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.)