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UNITED STATES 

SECURITIES AND EXCHANGE COMMISSION 

Washington, D.C. 20549 

FORM MSD 

APPLICATION FOR REGISTRATION AS A MUNICIPAL SECURITIES DEALER
 

PURSUANT TO RULE 15Ba2-1 UNDER THE SECURITIES EXCHANGE ACT OF 1934
 

OR AMENDMENT TO SUCH APPLICATION
 

GENERAL INSTRUCTIONS
 

A. Use of Form

This form is to be used by a bank or a separately identifiable department or division of a bank (as defined by the Municipal Securities

Rulemaking Board) to apply for registration as a municipal securities dealer with the Securities and Exchange Commission pursuant to 

section 15B(a) of the Securities Exchange Act of 1934 (the “Act”), or to amend such application. If applicant is a department or division 

of a bank, the application or amendment shall be deemed to have been made by the bank on behalf of the applicant. 

B. Presentation of Information

All information required by Form MSD must be submitted in typewritten or printed manner on the prescribed form or mechanical

reproductions thereof. The execution page on each copy of the form must contain an original manual signature of the appropriate duly 

authorized individual. Mechanical reproductions of signatures for this purpose are not acceptable. All other pages containing correct 

information may be mechanically reproduced by any method producing clear, legible copies of identical type size. Retain one exact copy 

for your records. 

Additional copies of Form MSD are available from the Securities and Exchange Commission, Washington, D.C. 20549. 

C. Signature

Form MSD shall be signed in the name of the applicant by a principal officer of the applicant or, if applicant is a department or

division of a bank, by a principal officer of the bank, in each case duly authorized to sign this Form, who is directly engaged in the 

management, direction or supervision of the applicant’s municipal securities dealer activities. 

D. Additional Space

If the space provided for any answer on Form MSD, other than the Schedules to the Form, is insufficient, the answer may be

completed on an additional sheet attached to the Form and appropriately identified. 

E. Names

Individuals’ names, except for executing signatures, shall be given in full wherever required (last name, first name, middle name).

The full middle name is required. Initials are not acceptable unless the individual legally has only an initial. If so,indicate this after the 

initial. 

F. Acceptance for Filing

A Form MSD which is not prepared and executed in compliance with applicable requirements may be returned as not acceptable

for filing. However, acceptance of this Form shall not constitute any finding that it has been filed as required or that the information 

submitted is true, current, or complete. 

G. General Definitions

a. Unless the context clearly indicates otherwise or unless otherwise specified in these instructions, all terms used in Form MSD have

the same meaning as in the Act and the General Rules and Regulations of the Securities and Exchange Commission. In particular, the

terms “self-regulatory organization,” “rules of a self-regulatory organization,” “municipal securities,” “municipal securities dealer,”

“person associated with a municipal securities dealer,” “municipal securities investment portfolio,” “appropriate regulatory agency,”

and “records” shall have the respective meanings set forth in sections 3(a)(26), 3(a)(28), 3(a)(29), 3(a)(30), 3(a)(32), 3(a)(33),

3(a)(34), and 3(a)(37) of the Act.

b. Jurisdiction — The term “jurisdiction” means a state, a territory, the District of Columbia, the Commonwealth of Puerto Rico, or any 

SEC1534 (02-08) 

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. 
subdivision or regulatory body thereof. 

c. Person — The term “person” includes a corporation, partnership, other organization, trust and estate, as well as natural person. 

d. Municipal securities dealer activities — The term “municipal securities dealer activities” has the meaning set forth in Municipal 

Securities Rulemaking Board rule G-1(b), which defines the terms “separately identifiable department or division of a bank” for 

purposes of Section 3(a)(30) of the Securities Exchange Act of 1934. 

H. Amendments 

The information contained in Form MSD is of a continuing nature and must be updated or amended periodically in the event 

any of the information previously submitted to the Commission becomes incomplete or inaccurate. Where an item is being amended, 

only those items which are being amended or which have changed since the previous filing need to be filed, except that a completed 

page one and a completed execution page, manually signed, must be filed with each amendment. WHEN ANY ITEM ON A PAGE 

IS AMENDED, IT IS NECESSARY TO ANSWER IN FULL ALL OTHER ITEMS ON THE PAGE BEING AMENDED. 

I. Items Not Applicable 

If Form MSD is being filed as an application for registration, all applicable items must be answered in full. If any item is not 

applicable, indicate by “none” or “N/A” as appropriate. 

J. Schedules to Form 

Each Schedule to Form MSD is deemed to be a part of the Form. 

K. Filing of Form 

Form MSD must be filed in triplicate with the Securities and Exchange Commission, Washington, D.C. 20549. The execution 

page of each copy shall contain an original manual signature. In addition, an original signed copy of the Form must be filed with 

the applicant’s appropriate regulatory agency, determined in accordance with section 3(a)(34) of the Act. Applicants which are 

national banks, or departments or divisions of such banks, must file Form MSD with the Comptroller of the Currency, Credit & 

Market Risk, 250 E Street, SW, MS 9-14, Washington, D.C. 20219; applicants which are State member banks of the Federal Reserve 

System, or departments or division of such banks, must file Form MSD with the Board of Governors of the Federal Reserve System, 

Risk Policy Section, Mail Stop 1810, 20th and C Streets, NW, Washington, D.C. 20551; applicants which are banks insured by 

the Federal Deposit Insurance Corporation (other than members of the Federal Reserve System), or departments or divisions 

of such banks, must file Form MSD with the Federal Deposit Insurance Corporation, 550 17th Street, NW,Washington, D.C. 

20429; applicants which are federal saving associations, or departments or divisions of such savings associations, must file 

Form MSD with the Office of Thrift Supervision, Assistant Managing Director, Examinations and Supervision Policy, 1700 G 

Street, NW, Washington, D.C. 20552. 

L. Instructions to Specific Items 

a. Item 1(a) — If the applicant is not registered currently with the Commission and is not succeeding to and continuing the business 

of another registered municipal securities dealer, the box marked “a new application” should be checked. If a registered municipal 

securities dealer is amending items on a currently effective Form MSD, the box marked “an amendment” should be checked. If 

the applicant is succeeding to and continuing the business of another registered municipal securities dealer, the box marked “a 

successor application” should be checked. If a bank registered as a municipal securities dealer determines it would prefer to 

register as a separately identifiable department or division, or the converse, it is necessary that (i) the applicant file a Form MSD, 

indicating in Item 1 that it is a “successor application” and (ii) the currently registered entity file a Form MSDW to withdraw its 

registration. Pursuant to Securities Exchange Act Rule 15Ba2-4, 17 CFR 240.15Ba2-4, if a municipal securities dealer succeeds 

to and continues the business of another registered municipal securities dealer, the registration of the predecessor shall be deemed 

to remain effective as the registration of the successor for a period of 75 days after such succession, provided that a Form MSD 

is filed by such successor within 30 days after such succession. 

b. Items 2(a) and 2(b) — If applicant is a department or division of a bank, these items should be answered only for applicant, rather 

than for the bank. Information with respect to the bank of which applicant is a part must be given in response to item 2(d). 

c. Item 5 — This item calls for information concerning persons directly engaged in the supervision of any of the applicant’s 

municipal securities dealer activities. A separate Schedule A or Form MSD-4 (which may be obtained from the appropriate 

regulatory authority) must be completed for each person named in response to Item 5. 

d. Item 6 — This item calls for information concerning persons not named in item 5 who may nevertheless directly or indirectly 

control any of applicant’s municipal securities dealer activities. Such control may be exercised through stock ownership, 

agreement or otherwise. Generally a person will be deemed to be in direct or indirect control of applicant’s municipal securities 

dealer activities if such person exercises or has the ability to exercise a controlling influence over the management or policies 

of applicant with respect to any of applicant’s municipal securities dealer activities. Depending on the fact of a particular situation, 

senior officers or directors of the applicant or of the bank of which applicant is a part, or of a parent bank holding company, may 

be deemed to be in direct or indirect control of such activities. Schedule A is not required for any person named in response to 

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item 6, but information is required to be furnished on Schedule B for each such person. 

e. Item 7 — The information required by this item must be furnished with respect to each person directly or indirectly engaged in 

or controlling any of the applicant’s municipal securities dealer activities, including any employee. 

f. Item 9 — This item relates to services performed by persons other than applicant with respect to applicant’s municipal securities 

dealer activities. There need not be furnished in response to this item information concerning personnel, payroll and other 

administrative services which are not directly related to the applicant’s municipal securities dealer activities. 

M. Privacy Act Statement 

Under Section 15, 15B(a), 17(a) and 23(a) of the Securities Exchange Act of 1934 and the Rules and Regulations thereunder, 

the Commission is authorized to solicit the information required to be supplied by this form from applicants for registration as a 

municipal securities dealer (and persons associated with applicants). Disclosure of the information specified on this form is 

mandatory prior to processing of applications for registration as a municipal securities dealer. The information will be used for 

the principal purpose of determining whether the Commission should grant or deny registration to the applicant. Information 

supplied on this form will be included routinely in the public files of the Commission and will be available for inspection by any 

interested person. A form which is not prepared and executed in compliance with applicable requirements may be returned as not 

acceptable for filing. Acceptance of this form, however, shall not constitute any finding that it has been filed as required or that 

the information submitted is true, current or complete. Intentional misstatements or omissions of fact constitute federal 

criminal violations. [See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a)]. 

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FORM MSD 

Page 1 

APPLICATION FOR REGISTRATION AS A 

MUNICIPAL SECURITIES DEALER PURSUANT TO RULE 15Ba2-1 

UNDER THE SECURITIES EXCHANGE ACT OF 1934 

OR AMENDMENT TO SUCH APPLICATION 

OFFICIAL USE 

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS

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

GENERAL: Form MSD is to be used by a bank or a separately identifiable department or division of a bank (as defined by the 

Municipal Securities Rulemaking Board) to apply for registration as a municipal securities dealer with the Securities and Exchange Commission pursuant to section 15B(a) of the Securities Exchange Act of 1934 (the “Act”) or to amend such application. If applicant is a department or division of a bank, the application or amendment shall be deemed to have been made by the 

bank on behalf of the applicant. Read all instructions before preparing the Form. If this Form is filed as an amendment, only a 

completed page one, a completed and signed execution page, and those items which are being amended or which have changed 

since the previous filing need to be filed. Please print or type all responses 

IN COMPLIANCE WITH THE APPLICABLE SECURITIES LAWS,
 

THE APPLICANT HEREBY SUBMITS THE FOLLOWING INFORMATION:
 

1. (a) This Form is filed with the Securities and Exchange Commission as:

 A new application An amendment A successor application 

(b) Applicant is a:

Bank Department or Division of a Bank 

2. (a) Name of applicant: 

Full name of applicant: _____________________________________________________________________________________ 

Name under which municipal securities dealer activities are conducted, if different: ________________________________ 

____________________________________________________________________________________________________________ 

If name of applicant is hereby amended, state name under which registered previously: __________________________ 

____________________________________________________________________________________________________________ 

If name under which municipal securities dealer activities are conducted is hereby amended, state name given 

previously: _______________________________________________________________________________________________ 

(b) Address and telephone number of principal office at which applicant’s municipal securities dealer activities are 

conducted: 

______________________________________________________________________________________________________________________________ 

Address of principal office: Number and Street City State Zip Code 

________________________________________________________________________________________________________________________________ 

Mailing address if different: Number and Street City State Zip Code 

Telephone Number: ___________________________________________________________


 Area Code Telephone Number
 

ALL OF THE ITEMS ON THIS PAGE MUST BE ANSWERED AND COMPLETED IN FULL 

DO NOT WRITE BELOW THIS LINE . . . . FOR OFFICIAL USE ONLY 

GEO. CODE FILING DATE BANK DIV. MAIL CODE EFFECTIVE DATE 

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FORM MSD Page 2 

OFFICIAL USE 

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS

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

2. (c) Name, title, mailing address and telephone number of person to contact with respect to applicant’s municipal securities dealer 

activities: 

__________________________________________________________________________________________________________ 

Name Title 

__________________________________________________________________________________________________________ 

Mailing address: Number and Street City State Zip 

Code 

Telephone Number: ___________________________________________________________________ 

Area Code Telephone Number 

(d) If applicant is a department or division of a bank, name, principal business address, mailing address, if different, and telephone 

number of bank: 

Full name of bank: ________________________________________________________________________________________ 

__________________________________________________________________________________________________________ 

Address of principal place of business: Number and Street City State Zip Code 

__________________________________________________________________________________________________________ 

Mailing address if different: Number and Street City State Zip Code 

Telephone Number:_________________________________________________ __________________

 Area Code Telephone Number 

(e) Applicant agrees and consents that the notice of any proceeding under the Act involving applicant may be given by sending 

such notice by mail or confirmed telegram to the person named, at the address given, in response to item 2(c). 

3. List below each jurisdiction in which applicant, or the bank of which applicant is a part, is filing or has filed an application for 

registration or license as a municipal securities dealer or in which applicant, or the bank of which applicant is a part, is so registered 

or licensed: 

_______________________________________________ ____________________________________________________ 

_______________________________________________ ____________________________________________________ 

_______________________________________________ ____________________________________________________ 

_______________________________________________ ____________________________________________________ 

4. (a) Indicate whether applicant, or the bank of which applicant is a part, is a national banking association or 

operated under the District of Columbia Code: 

YES NO 

(b) If applicant is a bank, the date of applicant’s organization. If applicant is a department or division 

of a bank, the date of the bank’s organization: _____________________________________________ 

(c) If applicant, or the bank of which applicant is a part, is a state-chartered bank, indicate whether 

applicant or such bank is: 

(1) a member of Federal Reserve System: 

YES NO 

(2) if not a member of the Federal Reserve System, insured by the Federal Deposit 

Insurance Corporation: 

5
 

YES NO 

If any item on this page is amended, you must answer in full all other items on this page and file 

with a completed page 1, and signed execution page. No Schedule required by any item on this page 

need be filed with an amended item unless the Schedule itself is amended. 
FORM MSD Page 3 

OFFICIAL USE 

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS

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

5. Furnish the following information for each person who is directly engaged in the management, direction or supervision of any of 

the applicant’s municipal securities dealer activities: 

(Place a double asterisk (**) next to the name of each person who is added to the names furnished in the most recent previous filing.) 

RELATIONSHIP Official

Use 

Only 

FULL NAME Beginning 

Date Title or Status 

Last First Middle Mo. Yr. 

01 

02 

03 

04 

05 

06 

07 

08 

09 

10 

11 

12 

13 

14 

15 

16 

17 

18 

If applicant is a department or division of a bank, place an asterisk (*) next to the name of each person listed above who has been designate d 

by the board of directors of the bank as responsible for the day-to-day conduct of the bank’s municipal securities dealer activities, includin g 

the supervision of all of the bank’s employees engaged in the performance of such activities. 

Complete a separate Schedule A or Form MSD-4 for each person named in response to item 5. If applicant is a department or division of a bank , 

attach as an exhibit to this Form a copy of the resolution or resolutions of the board of directors of the bank in which each person identified i n 

item 5 as having been designated by the board as responsible for the day-to-day conduct of the bank’s municipal securities dealer activities i s 

so designated. Such resolutions must be certified by an appropriate officer of the bank as having been duly adopted and as true, current, an d 

complete. 

If any item on this page is amended, you must answer in full all other items on this page and file with a 

completed page 1, and signed execution page. No Schedule required by any item on this page need be filed 

with an amended item unless the Schedule itself is amended. 

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FORM MSD Page 4 

OFFICIAL USE 

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS

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

6. Does any person not named in item 5 directly or indirectly control any of the applicant’s municipal YES NO 

securities dealer activities? ........................................................................................................... 

If “yes,” state on Schedule B the exact name and business (or if none, residence) address of each such person (if 

an individual, state last, first and middle names) and describe the basis through which such person directly or 

indirectly controls applicant’s municipal securities dealer activities. If applicant is a department or division of a 

bank and any such person has been designated by the board of directors of the bank as responsible for the day-today conduct of the bank’s municipal securities dealer activities, so indicate in Schedule B and explain why such 

person is not named in item 5. 

7. (a) State whether the applicant, any person named in response to item 5 or 6, or any person directly engaged 

in the management, direction, supervision or performance of any of the applicant’s municipal securities dealer 

activities, or who directly or indirectly controls any of such activities or who is directly or indirectly controlled 

by applicant in connection with any of such activities, including any employee: 

(i) Has been found by the Securities and Exchange Commission or an appropriate regulatory agency or any 

jurisdiction willfully to have made or caused to be made any statement which was, at the time and in the 

light of the circumstances under which it was made, false and misleading with respect to any material fact, 

or to have omitted to state any material fact, which was required to be stated, in any application for 

registration or report required to be filed under the Federal securities laws or under the securities law of 

any jurisdiction, or in any proceeding before the Securities and Exchange Commission or an appropriate 

regulatory agency or any jurisdiction relating to securities or the conduct of business or registration as a 

broker, dealer, municipal securities dealer or investment adviser or associated person thereof YES NO 

.............................................................................................................................................. 

(ii) Has been convicted within 10 years of any felony or misdemeanor (1) involving the purchase or sale of 

any security, the taking of a false oath, the making of a false report, bribery, perjury, burglary, or 

conspiracy to commit any such offense; (2) arising out of the conduct of the business of a broker, dealer, 

municipal securities dealer, investment adviser, bank, insurance company, or fiduciary; (3) involving the 

larceny, theft, robbery, extortion, forgery, counterfeiting, fraudulent concealment, embezzlement, fraudulent 

conversion, or misappropriation of funds or securities; or (4) involving the violation of Sections 152, 1341, 

1342 or 1343 or Chapters 25 or 47 of Title 18, United States Code (concealment of assets, false oaths and 

claims, or bribery, in any bankruptcy proceeding; mail fraud, fraud by wire, including telephone, 

telegraph, radio or television; counterfeiting, forgery, fraud, false statements); or has pleaded nolo YES NO 

contendere to any such felony or misdemeanor......................................................... 

(iii)Is enjoined permanently, or within the past 10 years has been enjoined temporarily, by order, judgment 

or decree of any court of competent jurisdiction from acting as an investment adviser, underwriter, broker, 

dealer, or municipal securities dealer or as an associated person or employee of any of the foregoing, or 

as an affiliated person or employee of any investment company, bank, or insurance company, or from 

engaging in or continuing any conduct or practice in connection with any such activity, or in connection 

with the purchase or sale of any security, or arising out of any securities or investment advisory YES NO 

activities.............................................................................................................................. 

(iv) Has been found by the Securities and Exchange Commission or an appropriate regulatory agency or any 

jurisdiction or any court to have violated or to have aided, abetted, counselled, commanded, induced, or 

procured the violation by any other person of the Federal laws, or the laws of any jurisdiction, relating to 

securities or relating to the conduct of business as a broker, dealer, municipal securities dealer, investment 

adviser, or investment company, any rule or regulation under any of such laws, or any rule of the Municipal 

Securities Rulemaking Board, or to have failed reasonably to supervise another person who committed YES NO 

such a violation, or to have been unable to comply with any of the foregoing ................... 

(v) Has been the subject of an order of the Securities and Exchange Commission entered pursuant to 

paragraph (6) of Section 15(b) or paragraph (4) of Section 15B(c) of the Securities Exchange Act of 1934 

or an order of a court or jurisdiction, or an order of an appropriate regulatory agency entered pursuant to 

paragraph (5) of Section 15B(c) of the Securities Exchange Act of 1934, barring or suspending the right 

of such person to be associated with a broker or dealer or municipal securities YES NO 

dealer................................................................................................................................................ 

If any item on this page is amended, you must answer in full all other items on this page and file 

with a completed page 1, and signed execution page. No Schedule required by any item on this page 

need be filed with an amended item unless the Schedule itself is amended. 

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FORM MSD Page 5 

OFFICIAL USE 

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS

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

7. (a) (vi) Has been denied membership or registration with, or participation in, or has been suspended, revoked or 

expelled from membership, participation in or registration with any self-regulatory organization, or has 

been suspended or barred from being associated with any member of a self-regulatory YES NO 

organization.................................................................................................................................... 

(vii) Has been denied registration (license) with, or suspended, revoked or expelled from registration (license) 

with the Securities and Exchange Commission or any jurisdiction as a broker, dealer, investment adviser, 

securities salesman, or municipal securities dealer, or has been barred from being associated with a YES NO 

person engaged in such business .................................................................................... 

(viii) Has been found to have been a cause of (1) the denial, suspension, or revocation of any person’s 

membership or participation in, or registration with the Securities and Exchange Commission, any 

jurisdiction, or any self-regulatory organization, (2) any bar or suspension of any person from being 

associated with a broker, dealer, municipal securities dealer, or member of a self-regulatory organization, YES NO 

or (3) any expulsion of any person from a self-regulatory organization .............................................. 

(ix) Has willfully made or caused to be made any statement which was, at the time and in the light of the 

circumstances under which it was made, false and misleading with respect to any material fact, or has 

omitted to state any material fact, which was required to be stated, in any application for membership or 

participation in, or to become associated with a member of, a self-regulatory organization, in any report 

required to be filed with a self-regulatory organization, or in any proceeding before a self-regulatory YES NO 

organization .................................................................................................................... 

(x) Has been, within the past 10 years, the subject of any cease and desist, desist and refrain, prohibition, or 

similar order which was issued by the United States or any jurisdiction arising out of the conduct of the YES NO 

business of a broker, dealer, municipal securities dealer or investment adviser ............................ 

(xi) Has been associated at any time as an officer, director, general partner, or owner of 10 percentum or more 

of the voting securities, or has at any time directly or indirectly through agreement or otherwise exercised 

or had the power to exercise a controlling influence over the management or policies of, a broker or dealer 

or municipal securities dealer which has been adjudicated bankrupt or a broker or dealer for which a YES NO 

trustee has been appointed pursuant to the Securities Investor Protection Act of 1970 ..... 

(xii) Has been the subject of any order, judgment, decree or other sanction of a foreign court, foreign exchange, 

or foreign government or regulatory agency arising out of any securities or investment advisory activities YES NO 

........................................................................................................................... 

(b) State whether applicant, or any person named in response to item 5 or 6, or any other person directly engaged 

in the management, direction, supervision or performance or any of the applicant’s municipal securities dealer 

activities, or who directly or indirectly controls any of such activities or who is directly or indirectly controlled YES NO 

by applicant in connection with any of such activities, including any employee, is presently the subject of any 

proceedings in which an adverse decision would result in any of the foregoing questions in part (a) being 

answered “yes”.......................................................................................................................... 

If the answer to any paragraph of item 7 is “yes,” explain on Schedule A. 

8. Each jurisdiction with which applicant, or the bank of which applicant is a part, is licensed or registered as a 

municipal securities dealer or to which application has been made should be listed in item 3. If any license or 

registration listed therein is of a restricted nature or has been suspended or if any license or registration not listed 

in item 3 was terminated, or withdrawn or voluntarily terminated, explain fully on Schedule C. 

9. Does applicant, or the bank of which applicant is a part, have any arrangement with any other person to perform YES NO 

any services for applicant or for the bank relating to applicant’s municipal securities dealer activities? ............. 

If “yes,” explain on Schedule C hereto, identifying each such other person, the nature of applicant’s relation, if any, 

to such persons, the nature of such services, and the arrangements pursuant to which such services are performed. 

If any item on this page is amended, you must answer in full all other items on this page and file 

with a completed page 1, and signed execution page. No Schedule required by any item on this page need be filed 

with an amended item unless the Schedule itself is amended. 

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FORM MSD Page 6 

OFFICIAL USE 

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS

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

YES NO 

10. (a) If applicant is a bank, does applicant maintain a municipal securities investment portfolio? ..................... 

(b) If applicant is a bank, does applicant buy and sell municipal securities in a fiduciary capacity or as agent for YES NO 

customers? .............................................................................................................................................. 

(c) If applicant is a bank, does any person named in item 5 above or any person controlled by applicant in 

connection with applicant’s municipal securities dealer activities, including any employee, engage in any YES NO 

activities of the bank with respect to municipal securities other than municipal securities dealer activities? 

If the answer to (c) is “yes” explain fully on Schedule C, setting forth the name of each such person, if such 

person is named in item 5, or the function performed by each such person if not so named, and the nature of 

each such person’s activities other than municipal securities dealer activities. 

11. How many employees does applicant have engaged in its municipal securities dealer activities? 

SUPERVISORY AND MANAGERIAL:

 OTHER: 

12. If applicant is a department or division of a bank: 

(a) Identify on Schedule C each geographic, organizational and operational unit of the bank of which applicant 

is a part in which applicant’s municipal securities dealer activities are conducted, specifying the name and 

location of each such unit and the nature of the municipal securities dealer activities conducted in each such 

unit. Indicate on Schedule C whether any business activities other than municipal securities dealer activities 

are conducted in any such unit, and describe the nature of such other activities. 

(b) Does any unit of the bank of which applicant is a part, other than those identified in response to item 12(a), YES NO 

perform any municipal securities dealer activities? .................................................................................. 

If the answer to (b) is “yes,” explain on Schedule C hereto, identifying each such unit and the nature of the 

activities performed by such unit. 

(c) Are all records relating to applicant’s municipal securities dealer activities maintained separate and apart from YES NO 

all other records of the applicant or of the bank of which applicant is a part? ................................... 

(d) Are all records relating to applicant’s municipal securities dealer activities separately extractable from YES NO 

applicant’s facilities or from the facilities of the bank of which applicant is a part? .................................. 

Describe on Schedule C the manner in which all records relating to applicant’s municipal securities dealer 

activities are maintained, including their location, how such records are collected and retrieved, the period of 

time required to collect or retrieve any such record, the category of employees having authority to collect or 

retrieve such records, and the name of each person who supervises the maintenance of such records. 

(e) Are separate financial records maintained with respect to applicant’s municipal securities dealer activities? YES NO 

If the answer to (e) is “yes,” explain on Schedule C the nature of such separate financial records. 

(f) Does the bank of which applicant is a part maintain a municipal securities investment portfolio? ............ YES NO 

(g) Does the bank of which applicant is a part buy and sell municipal securities in a fiduciary capacity or as agent YES NO 

for customers? ......................................................................................................................................... 

(h) Does any person named in item 5 above or any person controlled by applicant in connection with applicant’s 

municipal securities dealer activities, including any employee, engage in any activities of the bank with respect YES NO 

to municipal securities other than municipal securities dealer activities? ...................................... 

If the answer to (h) is “yes,” explain fully on Schedule C, setting forth the name of each such person if such 

person is named in item 5 or the function performed by each such person if not so named, and the nature of each 

such person’s activities other than municipal securities dealer activities. If any of such other activities with 

respect to municipal securities are performed by applicant, so specify on Schedule C. 

If any item on this page is amended, you must answer in full all other items on this page and file 

with a completed page 1, and signed execution page. No Schedule required by any item on this page 

need be filed with an amended item unless the Schedule itself is amended. 

9
 
FORM MSD Execution Page 

OFFICIAL USE 

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS

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

EXECUTION: 

STATE OF ________________________________________ 

COUNTY OF } ss: _____________________________________

The undersigned, being first duly sworn, deposes and says that he or she has executed 

this Form on behalf of, and with the authority of, the applicant named in item 2(a) and, if 

applicant is a department or division of a bank, on behalf of, and with the authority of, the 

bank named in item 2(d). The undersigned represents that the information and statements 

contained herein, including exhibits attached hereto and other information filed herewith, all 

of which are made a part hereof, are, to the best of the undersigned’s knowledge and belief 

and on the basis of diligent inquiry, current, true, and complete. The undersigned further 

represents that to the extent any information previously submitted is not amended, such 

information is, to the best of the undersigned’s knowledge and belief and on the basis of 

diligent inquiry, current, true, and complete. 

Dated the ____________________________ day of __________________________ , 20 _____ 

________________________________________________________________________________ 

(Name of Applicant) 

________________________________________________________________________________ 

(Manual signature of duly authorized officer) 

________________________________________________________________________________ 

(Title) 

Subscribed and sworn 

to before me this 

____________________________ day of ____________________________ , 20____ 

_______________________________________________________________________ 

(Notary Public) 

My commission expires: 

____________________________________ 

10
 
Schedule A of FORM MSD 

(Answers in response to items 5 and 7 of FORM MSD) 

OFFICIAL USE 

NOTE: (a) Complete a separate Schedule A for each person named in item 5 and each person subject to any action reported under 

item 7. 

(b) State all names in the order of last name, first name, full middle name. If any person legally has only an initial, so indicate 

after the initial. 

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS 

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

I. Full name of applicant exactly as stated in item 2(a) of Form MSD: 

II. Full name of person for whom this Schedule is being completed: 

III. (a) Residence address of person for whom this Schedule is being completed: 

NUMBER AND STREET CITY STATE ZIP 

IV. NAMES USED: Furnish below a list of all names individual has been known by or has used, including maiden name if applicable. 

If no other names used, state “None.”

 LAST FIRST MIDDLE LAST FIRST MIDDLE 

V. EDUCATION. Furnish below a description of the education of the person named in item II of this Schedule (include name and 

location of last high school attended, name and location of any college or university attended, degree or degrees received and year 

or years in which received). 

VI. BUSINESS BACKGROUND: Furnish below a complete, consecutive statement of all business experience and employment 

for the past ten years. List the last position first. If none, state “None.” 

Name of Firm and Address Kind of Business Exact Nature of Connection Beginning Date Ending Date

 or Employment Mo. Yrs. Mo. Yrs. 

VII.PROCEEDINGS: If any answer to any paragraph of item 7 is “Yes” with respect to the person for whom this Schedule is 

being completed, furnish the following details: 

Applicable Title or Description Name and Location of Court, 

Paragraph of Action Agency, Jurisdiction or Nature and Date

 of Item 7 Self-Regulatory Organization of Disposition of Proceeding 

If any item on this page is amended, you must answer in full all other items on this page and file with a completed page 1, 

and signed execution page. No Schedule required by an item on this page need be filed with an amended item unless 

the Schedule itself is amended. 

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Schedule B of FORM MSD 

(Answers in response to item 6 of FORM MSD) 

OFFICIAL USE 

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS

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

I. Full name of applicant exactly as stated in item 2(a) of Form MSD: 

II. Information with respect to persons described in item 6 of Form MSD: 

FULL NAME 

Last First Middle BASIS FOR CONTROL __ _________________________________________ _________________ ______________________________ 

If any item on this page is amended, you must answer in full all other items on this page and file with a completed 

page 1, and signed execution page. No Schedule required by an item on this page need be filed with an amended 

item unless the Schedule itself is amended. 

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Schedule C of FORM MSD 

OFFICIAL USE 

ATTENTION: INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT CONSTITUTE FEDERAL CRIMINAL VIOLATIONS

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

I. Full name of applicant exactly as stated in item 2(a) of Form MSD: 

II. Item of Form

 (identify) ANSWER 

If any item on this page is amended, you must answer in full all other items on this page and file with a completed 

page 1, and signed execution page. No Schedule required by an item on this page need be filed with an amended 

item unless the Schedule itself is amended. 

13