Uniform Termination Notice forMunicipal Securities Principal or Municipal Securities Representative Associatedwith a Bank Municipal Securities Dealer (MSD-5)

• Legal Form Number: FDIC6200/55
• Section: Federal Deposit Insurance Corporation

Page 1 of 3FDIC 6200/55 (6-21)

FDIC OMB No. 3064-0022; Expiration Date: 06/30/2024

FRB OMB No. 7100-0100; Expiration Date: 07/31/2022

OCC OMB No. 1557-0184; Expiration Date: 09/30/2022

Federal Deposit Insurance Corporation

FORM MSD-5

UNIFORM TERMINATION NOTICE FOR MUNICIPAL SECURITIES PRINCIPAL OR

MUNICIPAL SECURITIES REPRESENTATIVE ASSOCIATED WITH A BANK

MUNICIPAL SECURITIES DEALER

The Board of Governors of the Federal Reserve System, the Federal Deposit Insurance Corporation, and the Office of the Comptroller of the Currency

are authorized to collect this information pursuant to the authority contained in the following statutes: 15 U.S.C. §§

78o-4, 78q, and 78w.

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 Office

of Management and Budget (OMB) control number. The information provided by each respondent is considered to be confidential.

FEDERAL DEPOSIT INSURANCE CORPORATION PRIVACY ACT NOTICE

The FDIC is authorized to request this information from you by Sections 15B(c), 15C, 17 and 23 of the Securities Exchange Act of 1934 (15 U.S.C.

78o-4, 78o-5, and 78q and 78w); and Section 9 of the Federal Deposit Insurance Act (12 U.S.C. 1819). The purpose for collecting the information is to

comply with the registration requirements of municipal securities dealers, municipal securities representatives, and U.S. Government securities brokers

or dealers and associated persons contained in the Securities Exchange Act of 1934, and to support the FDIC's regulatory and supervisory functions.

Furnishing the requested information is mandatory. Failure to provide the requested information in whole or in part may delay or prohibit the

determination of your compliance with applicable registration and professional qualifications requirements. The information you provide is protected by

the Privacy Act, 5 USC 552(a). The information may be furnished to third parties as authorized by law and used according to any of the routine uses

described in the Professional Qualification Records for Municipal Securities Dealers, Municipal Securities Representatives, and U.S. Government

Securities Brokers/Dealers System of Records (30-64-0016) available at www.fdic.gov/about/privacy/index.html. If you have questions or concerns

about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at Privacy@fdic.gov.

BOARD OF GOVERNORS OF THE FEDERAL RESERVE SYSTEM PRIVACY ACT NOTICE

The Federal Reserve Board is authorized to request this information from you by Sections 3, 15B(c), 15C, 17 and 23 of the Securities Exchange Act of

1934 (15 U.S.C. 78c, 78o-4, 78o-5, and 78q and 78w); and Section 11 of the Federal Reserve Act (12 U.S.C. 248). The purpose for collecting the

information is to comply with the registration requirements of municipal securities dealers, municipal securities representatives, and U.S. Government

securities brokers or dealers and associated persons contained in the Securities Exchange Act of 1934, and to support the Board's regulatory and

supervisory functions. Furnishing the requested information is mandatory. Failure to provide the requested information in whole or in part may delay or

prohibit the determination of your compliance with applicable registration and professional qualification requirements. The information you provide is

protected by the Privacy Act, 5 U.S.C. 552(a). The information may be furnished to third parties as authorized by law and used according to any of the

routine uses as described in the system of Records entitled BGFRS-17” FRB --Municipal or Government Securities Principals or Representatives,”

available at https://www.federalreserve.gov/files/BGFRS-17-municipal-or-government-securities-principals-and-representatives.pdf. If you have any

questions or concerns about the collection or use of the information, you may contact the Secretary of the Board, Board of Governors of the Federal

Reserve System, 20th Street and Constitution Avenue, NW, Washington, DC 20551.

OFFICE OF THE COMPTROLLER OF THE CURRENCY PRIVACY ACT NOTICE

The Office of the Comptroller of the Currency is authorized to request this information from you by 12 U.S.C. 1, 481, 1464, 1818, and 1820; 15 U.S.C.

78o-4, 78o-5, 78q, and 78w. The purpose of collecting the information is for the OCC to carry out its responsibilities under the federal securities laws

relating to the professional qualifications and fitness of individuals who engage or propose to engage in securities activities on behalf of national banks,

federal savings associations, and District of Columbia savings associations operating under the OCC's regulatory authority. Failure to provide the

requested information in whole or in part may delay or prevent the determination of your compliance with applicable registration and professional

qualification requirements. The information you provide is protected by the Privacy Act, 5 U.S.C. 552(a). The information may be furnished to third

parties as authorized by law and used according to any of the routine uses described in the Bank Securities Dealers System --Treasury/Comptroller

system of record notice (Treasury/CC .210) available at https://www.federalregister.gov/documents/2016/01/19/2016-00763/privacy-act-of-1974-as-

amended-system-of-records. If you have any questions or concerns about the collection or use of the information, you may contact the Deputy

Comptroller, Market Risk Division, Office of the Comptroller of the Currency, 400 Seventh St S.W., Suite 7W-215, Washington D.C. 20219.

PAPERWORK REDUCTION ACT NOTICE

Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time to gather and maintain data in

the required form and to review instructions and to complete the information collection. Send comments regarding this burden estimate or any other

aspect of this collection of information, including suggestions for reducing this burden, to the Paperwork Reduction Act Clearance Officer, Legal

Division, Federal Deposit Insurance Corporation, 550 17th Street, N.W., Washington, D.C. 20429, and the Office of Management and Budget,

Paperwork Reduction Project (3064-0022) Washington, DC 20503.

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