FORM G-FIN-5

Uniform Termination Notice for Person Associated with a

Financial Institution Government Securities Broker or Dealer

 OMB #3064-0093 

Expires: 03/31/2025

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1. Individual’s Name

Last First Middle (If none, so specify)

2. Capacity

3. Social Security Number

4. Financial Institution Government Securities Broker or Dealer:

a. Name

b. Registration Number

c. Main Address

5. Office of Employment Address

6. Date Terminated

7. Reason for Termination - Check One:

Resigned* Discharged* Deceased Transfer* Other* 

*Furnish full details on attached sheet if related to a violation or probable violation of banking or securities law.

8. While associated, was the individual the subject of any investigation, proceeding, disqualification or disciplinary action by any governmental agency

pursuant to Section 15C of the Securities Exchange Act of 1934 (15 U.S.C. 78o-5)? **Yes No

**Furnish full details on attached sheet.

Date Print Name of Supervisor of Individual Signature of Supervisor of Individual

Person to Contact for Further Information 

ACCEPTANCE OF THIS FORM FOR FILING SHALL NOT CONSTITUTE ANY FINDING THAT THE INFORMATION SUBMITTED HEREIN IS TRUE, 

CURRENT, COMPLETE, OR NOT MISLEADING. INTENTIONAL MISSTATEMENTS OR OMISSIONS OF FACT MAY CONSTITUTE FEDERAL 

CRIMINAL VIOLATIONS. (See 18 U.S.C. 1001 and 1005, and 15 U.S.C. 78ff.)

FORM G-FIN-5 ACKNOWLEDGEMENT

Receipt Stamp 

9. Name of Individual

10. Financial Institution Broker or Dealer Name

11. Financial Institution Broker or Dealer Address

12. Attention

WHEN THE FORM G-FIN-5 IS RECEIVED BY THE APPROPRIATE REGULATORY AGENCY, THIS ACKNOWLEDGEMENT WILL BE STAMPED TO 

SHOW RECEIPT AND RETURNED TO THE PERSON NAMED IN ITEM 12. THE STAMPED ACKNOWLEDGEMENT SHOULD BE RETAINED TO 

SUBSTANTIATE FILING.
G-FIN-5

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INSTRUCTIONS FOR COMPLETING AND FILING FORM G-FIN-5

GENERAL INSTRUCTIONS

This report is required by Section 15C of the Securities Exchange Act of 1934 (15 U.S.C. 78o-5) and the regulations 

thereunder, 17 CFR 400.4. The Department of the Treasury and the appropriate regulatory agencies, as defined below, 

regard the information provided by each respondent as confidential. 

1. As used in these instructions and Form G-FIN-5:

a. The term financial institution government securities broker or dealer means a government securities broker or

dealer that is a financial institution and that has not been exempted from regulation as a government securities

broker or dealer under Part 401 of Title 17, Code of Federal Regulations; and

b. The term person associated with a financial institution government securities broker or dealer means a person,

other than a person whose functions are solely clerical or ministerial, who is engaged in any of the following

activities in either a supervisory or non-supervisory capacity: (i) underwriting, trading or sales of government

securities; (ii) financial advisory or consultant services for issuers in connection with the issuance of government

securities; (iii) research or investment advice, other than general economic information or advice, with respect to

government securities in connection with the activities described in clauses (i) and (ii); (iv) activities other than

those specifically mentioned which involve communication, directly or indirectly, with public investors in

government securities in connection with the activities described in clauses (i) and (ii) above. The term also

includes anyone directly engaged in the following activities in a supervisory capacity: (i) processing and

clearance activities with respect to government securities and (ii) maintenance of records involving any of the

activities described in this paragraph (b).

Persons who function solely in a fiduciary capacity and persons whose sole government securities activities are,

without exercising any investment discretion and solely at the direction of customers, to receive and/or transmit

customer orders to purchase or sell government securities, but who do not give investment advice or receive

transaction-based compensation, are not “associated persons” and are not required to file this form. Directors

and senior officers of the financial institution who may from time to time set broad policy guidelines affecting the

financial institution as a whole that are not directly related to the conduct of the financial institution’s government

securities business are not considered to be “directly engaged” in the activities described in this paragraph and

are not required to file this form.

2. Form G-FIN-5 is to be used by financial institution government securities brokers and dealers to report the

termination of association of a person with the financial institution government securities broker or dealer as provided

in the rules of the Department of the Treasury, 17 CFR 400.4.

This form should be used only when a Form U-5 or MSD-5 has not been filed with respect to such person.

Termination includes transfer of an individual to another position in the financial institution that does not involve the

individual in the activities included in the definition of person associated with a financial institution government

securities broker or dealer.

3. Financial institution government securities brokers and dealers are required to file Form G-FIN-5 with the appropriate

regulatory agency as set forth below:

a. The Comptroller of the Currency in the case of a national bank, a bank in the District of Columbia examined by the

Comptroller of the Currency, or a Federal branch or Federal agency of a foreign bank (as such terms are used in

the International Banking Act of 1978);

b. The Board of Governors of the Federal Reserve System, in the case of a State member bank of the Federal

Reserve System, a foreign bank, an uninsured State branch or State agency of a foreign bank, a commercial

lending company owned or controlled by a foreign bank (as such terms are used in the International Banking Act

of 1978), or a corporation organized or having an agreement with the Board of Governors of the Federal Reserve

System pursuant to section 25 or section 25A of the Federal Reserve Act;
G-FIN-5

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c. The Federal Deposit Insurance Corporation, in the case of a bank insured by the Federal Deposit Insurance 

Corporation (other than a member of the Federal Reserve System or a Federal savings bank) or an insured State 

branch of a foreign bank (as such terms are used in the International Banking Act of 1978); and

d. The Securities and Exchange Commission, in the case of all other financial institution government securities 

brokers and dealers.

4. Copies of Form G-FIN-5 may be obtained from any of the appropriate regulatory agencies listed in instruction 3.

5. An original and two copies of Form G-FIN-5 and any attachments are to be filed by the financial institution 

government securities broker or dealer with the appropriate regulatory agency listed in instruction 3 within 30 days 

after termination of the association of the individual named in item 1, except that (i) if the financial institution notifies 

the appropriate regulatory agency that the individual will remain in the financial institution’s employment and the 

financial institution continues to update information about such person as provided in 17 CFR 400.4(b), the Form GFIN-5 need not be filed until within 30 days after the termination of the individual’s employment with the financial 

institution, and (ii) if the financial institution is required to and has filed a Form U-5 or MSD-5 with respect to such 

person, the Form G-FIN-5 need not be filed. A financial institution government securities broker or dealer filing a 

Form G-FIN-5 shall retain an exact copy in its records for at least three years following its filing.

6. If more space is needed to complete an answer, an appropriate designation shall be entered in the answer space 

provided, and one or more attachment sheets shall be used to complete the response. All attachments shall be 

submitted in the same format as the items to which response is made and should be typed on white 8-1/2 by 11 inch 

paper. Answers to more than one question may appear on an attachment sheet if the questions are clearly identified. 

Attachments should be paginated and the name of both the applicant and the financial institution government

securities broker or dealer should appear on every attachment sheet.

7. Form G-FIN-5 and any attachments may be duplicated by any method which produces legible copies of type size 

identical to that of the Form G-FIN-5 on white 8-1/2 by 11 inch paper.

8. Form G-FIN-5 shall be manually signed by the supervisor of the person named in item 1.

9. All items on Form G-FIN-5 are to be completed, except that disclosure of the individual’s Social Security number is 

not required if that information is unavailable. The date on which the Form G-FIN-5 is received by the appropriate 

regulatory agency shall be the date of filing. A Form G-FIN-5 which is not prepared and executed in accordance with 

the applicable requirements may be returned as unacceptable for filing. Acceptance for filing shall not constitute any 

finding that a Form G-FIN-5 has been completed in accordance with those requirements or that any information 

reported on the form is true, correct, complete, or not misleading.

Public reporting burden for this collection of information is estimated to average 2 hours per response, 

including the time for reviewing instructions, searching existing data sources, gathering and maintaining 

the data needed, and completing and reviewing the collection of information. Send comments regarding 

this burden estimate or any aspect of this collection of information, including suggestions for reducing 

this burden to: FDIC Paperwork Reduction Act Clearance Officer, MB-3016, 17th Street, N.W., 

Washington, DC 20429; and to the Office of Management and Budget, (3064-0093) Washington, DC 

20503.