Uniform Termination Notice for Persons Associated with a Financial Institution Government Securities Broker orDealer (G-FIN-5)

• Legal Form Number: FDIC 6830/03
• Section: Federal Deposit Insurance Corporation

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

Page 1 of 3

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.