SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
AMENDMENT TO THE MUNICIPAL ADVISOR’S MOST RECENT FORM MA-I
OMB Number: 3235-0681
Estimated average burden hours per response: 0.5
Form MA-I Applicant's Information
Submission Contact Information
Notification Information
Notification will automatically be sent to the Login CIK, Submission Contact, and Primary Issuers. Specify additional addresses below.
Please read the General Instructions for this form and other forms in the MA series, as well as its subsection, "Specific Instructions for Form MA-I," before completing this form. All italicized terms herein are defined or described in the Glossary of Terms appended to the General Instructions.
PART 1
Every municipal advisory firm applying for registration or registered as a municipal advisor on Form MA, to provide information regarding each natural person who is an associated person of the firm and engages in municipal advisory activities on the firm's behalf (for purposes of Form MA-I, the "individual"); and
Every natural person (sole proprietor) applying for registration as a municipal advisor on Form MA, to provide additional personal information.
WARNING
Complete this form truthfully. False statements or omissions may result in denial of a municipal advisor's application, revocation or suspension of such registration, or criminal prosecution. Form MA-I must be amended promptly whenever any information previously provided becomes inaccurate. See General Instruction 9.
Type of Filing:
This is an (check the appropriate box):
Initial Form MA-I 
Amendment to the most recent Form MA-I Amendment to indicate that the individual is no longer an associated person of the municipal advisory firm or no longer engages in municipal advisory activities on its behalf. (If you check this box, complete only Item 1-A and Item 7 below.)Item 1 Identifying Information
A. The Individual
B. Municipal Advisory Firms Where the Individual Is Employed
In providing your responses, please note that the definition of "employee" for purposes of this form includes an independent contractor who engages in municipal advisory activities on behalf of a municipal advisory firm. See Glossary of Terms.
YES 
NO (For individuals who are employed with more than one firm, provide the information required by this Item 1-B for each such firm. For sole proprietors, enter the legal name under which you conduct your municipal advisor-related activities, and skip to Item 1-B.1.)
YES NO (1) Municipal Advisory Firm's Registration Information:
Notification will automatically be sent to the Login CIK, Submission Contact, and Primary Issuers. Specify additional addresses below.
YES NO (2) Office
Enter the requested information for each office of the municipal advisory firm where the individual is or will be physically located, and each office from which the individual is or will be supervised:
Located At Supervised From A private residential address will not be included in publicly available versions of this registration form.
YES NO Item 2 Other Names
Enter the following information for all other names that the individual has used or is using, or by which the individual is known or has been known, other than the individual´s legal name, since the age of 18.
This space should include, for example, nicknames, aliases, and names used before or after marriage.
Item 3 Residential History
Starting with the current address, enter the following information for all the individual´s residential addresses for the past 5 years. Leave no gaps greater than three months between addresses. Report changes in an amendment to this form as they occur in the future. Private residential addresses will not be included in publicly available versions of this form.
Current Address
Item 4 Employment History
Provide complete employment history of the individual for the past 10 years. Include the municipal advisory firm(s) entered in Item 1-B. Enter the following information for each employer. Account for all time, leaving no gaps longer than three months. Include full- and part-time employment, self-employment, military service, and homemaking. Also include statuses such as unemployed, full-time education, extended travel, or other similar statuses. Such statuses should be entered in the space provided below for "Name of Municipal Advisory Firm or Company."
Current Employer
YES NO YES NO Item 5 Other Business
YES NO If "Yes", please enter the following details for each other business below:
Other Business
YES NO YES NO Other Business
YES NO YES NO Other Business
YES NO YES NO Item 6 Disclosure Information
IF THE ANSWER TO ANY OF THE QUESTIONS IN ITEMS 6A – 6J AND 6M IS "YES," PROVIDE DETAILS OF ALL EVENTS OR PROCEEDINGS ON THE APPROPRIATE DISCLOSURE REPORTING PAGES (DRPs).
One event or proceeding may result in the requirement to answer "Yes" to more than one question below.
Refer to the Glossary of Terms for definitions or descriptions of italicized terms.
CRIMINAL ACTION DISCLOSURE
If the answer is "Yes" to any question below in Item 6A or 6B, complete a Criminal Action DRP.
Item 6A.
(1) Has the individual ever:
YES NO YES NO (2) Based upon activities that occurred while the individual exercised control over it, has an organization ever:
YES NO YES NO Item 6B.
(1) Has the individual ever:
(a) been convicted of any misdemeanor or pled guilty or nolo contendere ("no contest") in a domestic, foreign or military court to any charge of a misdemeanor involving: municipal advisory activities or a municipal advisor-related or 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?
YES NO (b) been charged with any misdemeanor of the kind described in 6B(1)(a)?
YES NO YES NO YES NO REGULATORY ACTION DISCLOSURE
If the answer is "Yes" to any question below in Items 6C-6G(1), complete a Regulatory Action DRP.
Item 6C.
Has the SEC or the CFTC ever:
(1) found the individual to have made a false statement or omission?
YES NO (2) found the individual to have been involved in a violation of any SEC or CFTC regulation or statute?
YES NO (3) found the individual to have been a cause of a denial, suspension, revocation, or restriction of the authorization of a municipal advisor-related business or investment-related business to operate?
YES NO (4) entered an order against the individual in connection with municipal advisor-related or investment-related activity?
YES NO (5) imposed a civil money penalty on the individual, or ordered the individual to cease and desist from any activity?
YES NO (6) found the individual to have willfully violated any provision of the Securities Act of 1933, the Securities Exchange Act of 1934, the Investment Advisers Act of 1940, the Investment Company Act of 1940, the Commodity Exchange Act, or any rule or regulation under any of such Acts, or any of the rules of the MSRB, or found the individal to have been unable to comply with any provision of such Acts, rules or regulations?
YES NO (7) found the individual to have willfully aided, abetted, counseled, commanded, induced, or procured the violation by any person of any provision of the Securities Act of 1933, the Securities Exchange Act of 1934, the Investment Advisers Act of 1940, the Investment Company Act of 1940, the Commodity Exchange Act, or any rule or regulation under any of such Acts, or any of the rules of the MSRB?
YES NO (8) found the individual to have failed reasonably to supervise another person subject to his or her supervision, with a view to preventing the violation of any provision of the Securities Act of 1933, the Securities Exchange Act of 1934, the Investment Advisers Act of 1940, the Investment Company Act of 1940, the Commodity Exchange Act, or any rule or regulation under any of such Acts, or any of the rules of the MSRB?
YES NO Item 6D.
(1) Has any other federal regulatory agency or any state regulatory agency or foreign financial regulatory authority ever:
(a) found the individual to have made a false statement or omission or to have been dishonest, unfair or unethical?
YES NO (b) found the individual to have been involved in a violation of municipal advisor-related or investment-related regulation(s) or statute(s)?
YES NO (c) found the individual to have been a cause of a denial, suspension, revocation, or restriction of the authorization of a municipal advisor-related or investment-related business to operate?
YES NO (d) entered an order against the individual in connection with a municipal advisor-related or investment-related activity?
YES NO (e) denied, suspended, or revoked the individual's registration or license or otherwise, by order, prevented the individual from associating with a municipal advisor-related or investment-related business or restricted his or her activities?
YES NO (2) Has the individual ever been subject to any final order of a state securities commission (or any agency or office performing like functions), a state authority that supervises or examines banks, savings associations, or credit unions, a state insurance commission (or any agency or office performing like functions), a federal banking agency, or the National Credit Union Administration, that:
(a) bars the individual from association with an entity regulated by such commission, authority, agency, or office, or from engaging in the business of securities, insurance, banking, savings association activities, or credit union activities; or
YES NO (b) is based on violations of any laws or regulations that prohibit fraudulent, manipulative, or deceptive conduct?
YES NO Item 6E.
Has any self-regulatory organization or commodities exchange ever:
(1) found the individual to have made a false statement or omission?
YES NO (2) found the individual 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 SEC)?
YES NO (3) found the individual to have been a cause of a denial, suspension, revocation, or restriction of the authorization of a municipal advisor-related or investment-related business to operate?
YES NO (4) disciplined the individual by expelling or suspending him or her from membership, barring or suspending the individual's association with its members, or restricting the individual's activities?
YES NO (5) found the individual to have willfully violated any provision of the Securities Act of 1933, the Securities Exchange Act of 1934, the Investment Advisers Act of 1940, the Investment Company Act of 1940, the Commodity Exchange Act, or any rule or regulation under any of such Acts, or any of the rules of the MSRB, or found the individual to have been unable to comply with any provision of such Acts, rules or regulations?
YES NO (6) found the individual to have willfully aided, abetted, counseled, commanded, induced, or procured the violation by any person of any provision of the Securities Act of 1933, the Securities Exchange Act of 1934, the Investment Advisers Act of 1940, the Investment Company Act of 1940, the Commodity Exchange Act, or any rule or regulation under any of such Acts, or any of the rules of the MSRB?
YES NO (7) found the individual to have failed reasonably to supervise another person subject to your supervision, with a view to preventing the violation of any provision of the Securities Act of 1933, the Securities Exchange Act of 1934, the Investment Advisers Act of 1940, the Investment Company Act of 1940, the Commodity Exchange Act, or any rule or regulation under any of such Acts, or any of the rules of the MSRB?
YES NO Item 6F.
YES NO Item 6G.
Has the individual been notified, in writing, that he or she is currently the subject of any:
YES NO INVESTIGATION DISCLOSURE
If the answer is "Yes" to Item 6G(2) below, complete an Investigation DRP.
YES NO CIVIL JUDICIAL ACTION DISCLOSURE
If the answer is "Yes" to any question below in Item 6H, complete a Civil Judicial Action DRP.
Item 6H.
(1) Has any domestic or foreign court ever:
YES NO YES NO YES NO YES NO CUSTOMER COMPLAINT/ARBITRATION/CIVIL LITIGATION DISCLOSURE
If the answer is "Yes" to any question below in Item 6I, complete a Customer Complaint/Arbitration/Civil Litigation DRP.
Item 6I.
(1) Has the individual ever been the subject of a municipal advisor-related or investment-related, customer-initiated (written or oral) complaint that alleged that he or she was involved in fraud, false statements, omissions, theft, embezzlement, wrongful taking of property, bribery, forgery, counterfeiting, extortion, or dishonest, unfair or unethical practices, which: YES NO YES NO YES NO YES NO YES NO TERMINATION DISCLOSURE
If the answer is "Yes" to any question below in Item 6J, complete a Termination DRP.
Item 6J.
Has the individual ever voluntarily resigned, been discharged or permitted to resign after allegations were made that accused him or her of:
YES NO YES NO YES NO FINANCIAL DISCLOSURE
Item 6K.
Within the past 10 years:
YES NO YES NO YES NO Item 6L.
YES NO JUDGMENT/LIEN DISCLOSURE
If the answer is "Yes" to any question below in Item 6M, complete a Judgment/Lien DRP.
Item 6M.
YES NO Item 7 Signature and Self-Certification
NOTE: In addition to completing Item 7, to the extent that the individual is a non-resident, a Form MA-NR completed and signed by the individual must be attached as an exhibit to this Form MA-I.
Complete Either Subpart A or Subpart B:
By typing a name in the signature field, the signatory acknowledges and represents that the entry constitutes in every way, use, or aspect, his or her legally binding signature.
A. For Municipal Advisory Firms filing this form:
The municipal advisory firm has obtained and retained written consent from the individual that service of any civil action brought by, or notice of any proceeding before, the SEC or any self-regulatory organization in connection with the individual's municipal advisory activities may be given by registered or certified mail to the individual's address given in Item 1.
I, the undersigned, sign this Form MA-I on behalf of, and with the authority of, the municipal advisory firm that is filing this form. The municipal advisory firm and I both certify, under penalty of perjury under the laws of the United States of America, that the information and statements made in this Form MA-I, including exhibits and any other information submitted, are true and correct, and that I am signing this Form MA-I as a free and voluntary act.
B. For Natural Person Municipal Advisors (Sole Proprietors) filing this form:
The individual named below consents that service of any civil action brought by, or notice of any proceeding before, the SEC or any self-regulatory organization in connection with the individual's municipal advisory activities may be given by registered or certified mail to the individual's address given in Item 1.
I, the undersigned, certify, under penalty of perjury under the laws of the United States of America, that the information and statements made in this Form MA-I, including exhibits and any other information submitted, are true and correct, and that I am signing this Form MA-I Execution Page as a free and voluntary act.
Full Legal Name of Municipal Advisor:
Enter all the letters of each name and not initials or other abbreviations. If no middle name, enter NMN on that line.
Warning: Intentional misstatements or omissions of fact constitute Federal criminal violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).12.
REGULATORY ACTION DISCLOSURE REPORTING PAGE (MA-I)
REGULATORY ACTION DRP - PART 1
This Disclosure Reporting Page (DRP MA-I) is an INITIAL ORAMENDED response to report details for affirmative response(s) to Question(s) 6C, 6D, 6E, 6F and 6G(1) on Form MA-I.
Check the question(s) to which this DRP pertains:
6C(1) 6D(1)(a) 6E(1) 6F 6G(1) 6C(2) 6D(1)(b) 6E(2) 6C(3) 6D(1)(c) 6E(3) 6C(4) 6D(1)(d) 6E(4) 6C(5) 6D(1)(e) 6E(5) 6C(6) 6D(2)(a) 6E(6) 6C(7) 6D(2)(b) 6E(7) 6C(8) YES NO The event or proceeding was resolved in the individual's favor The DRP was filed in error.
Explain the circumstances:
How to Report an Event or Proceeding on a Regulatory Action DRP : Use a separate DRP for each event or proceeding . One event may result in more than one affirmative answer to the above items. If an event gives rise to actions by more than one regulator, provide details for each action on a separate DRP.
Note: The filer may identify a DRP filed by the individual directly, or filed by another SEC registrant about the individual as an associated person.
NOTE: The completion of all or any part of this form does not relieve the individual or any municipal advisor with which the individual is associated of the obligation to update any relevant Form MA or IARD or CRD records.
REGULATORY ACTION DRP - PART 2
1. Regulatory Action was initiated by:
Other Federal Authority
Select only one box below. A separate Regulatory Action DRP is required for each such regulator or other authority.
SEC State Foreign Financial Regulatory AuthorityCFTC SROFederal Banking Agency National Credit Union Administration Other Federal Authority Other: (specify)
For a foreign financial regulatory authority, please provide the full name in English.
(select all that apply):
Bar (Permanent) Disgorgement Restitution Bar (Temporary/Time Limited) Expulsion Requalification Cease and Desist Injunction Revocation Censure Prohibition Suspension Civil and Administrative Penalty(ies)/Fine(s) Reprimand Undertaking Denial Rescission Other Sanction(s) Sought
(list each such additional sanction):
(specify)(if brought in a foreign jurisdiction, provide all the information below in English):
Street Address:
City or County:
State/Country:
Postal Code:
Provide the full legal name of the individual's employing firm, if any, when the activity occurred which led to the regulatory action (if there was no such employing firm at that time, enter "None"). Enter the employing firm's MA and CRD registration numbers, if any.
Check the appropriate item.
No Product Annuity-Charitable Direct Investment-DPP & LP Interest Oil & Gas Annuity-Fixed Equipment Leasing Options Annuity-Variable Equity Listed (Common & Preferred Stock) Penny Stock Banking Product Equity-OTC Prime Bank Instrument (other than CD) CD Futures-Commodity Promissory Note Commodity Option Futures-Financial Real Estate Security Debt-Asset Backed Index Option Security Futures Debt-Corporate Insurance Security-based Swap Debt-Government Investment Contract Swap Debt-Municipal Money Market Fund Unit Investment Trust Derivative Mutual Fund Viatical Settlement Other Principal Product Type: Yes No The date that notice or other process was served (MM/DD/YYYY):
YES NO Provide the name of the US regulator (i.e., the SEC, an SRO, other), federal court, state court or state regulator, or a foreign or international court or regulator to whom the individual appealed. If brought in a foreign jurisdiction, provide all the information below in English.
Street Address:
City or County:
State/Country:
Postal Code:
Are there any limitations or restrictions currently in effect while on appeal?
YES NO consider Item 14. For actions that are "Pending," skip to Item 14.
Check all the applicable boxes that reflect the most recent resolution of the matter by a regulator or a court, whether or not any part of the resolution is on appeal. If any part of the resolution is on appeal, identify in Item 11-B which part is currently on appeal.
Acceptance Waiver & Consent (AWC) Dismissed Stipulation and Consent Consent Judgment Rendered Withdrawn Decision Order Other (requires explanation) Decision & Order of Offer of Settlement Settled Appealed Affirmed Vacated Nunc Pro Tunc/ab initio Vacated & Returned For Further Action Vacated/Final Other (requires explanation) If more than one box in Item 11-A. is checked, or Other is checked, or Item 11-A. otherwise does not adequately summarize the type of resolution, provide an explanation. For example, if the individual appealed all or part of a resolution by the regulator or court, indicate what is being appealed.
If Order is checked above in Item 11-A., does the order constitute a final order based on violations of any laws or regulations that prohibit fraudulent, or deceptive conduct?
YES NO (For a resolution that is being appealed in part, the date to be provided should be the date on which the regulator (reviewing a decision by an SRO or an Administrative Law Judge) or a court provided its resolution.)
YES NO , none were ordered Bar (Permanent) Disgorgement* Restitution* Bar (Temporary/Time Limited) Expulsion Requalification Cease and Desist Injunction Revocation Censure Prohibition Suspension Civil and Administrative Penalty(ies)/Fine(s)* Reprimand Undertaking Denial Rescission Were one or more sanctions ordered that required a monetary payment?
YES NO (1) Barred, Enjoined, or Suspended:
If you selected one or more of these sanctions in Item 13-B. above, provide the corresponding information.
(a) Barred
If the individual in the above action one or more bars from registration capacities, associations, and/or other activities, and the terms specify different time periods, report each in a separate entry.
(i) Duration (length of time):
Permanent (not limited by length of time). Temporary / Time Limited. Specify the
Days
Months
Years
(ii) Start Date (MM/DD/YYYY):
(iii) End Date (MM/DD/YYYY):
(iv) Description: Provide remaining details, including any explanation boxes checked above, and the registration capacities affected (General Securities Principal, Financial Operations Principal, etc.):
If the individual received in the above action one or more injunctions from registration capacities, associations, and/or other activities, and the terms specify different time periods, report each in a separate entry.
(i) Duration (length of time):
Permanent (not limited by length of time). Temporary / Time Limited. Specify the
Days
Months
Years
(ii) Start Date (MM/DD/YYYY):
(iii) End Date (MM/DD/YYYY):
(iv) Description: Provide remaining details, including any explanation boxes checked above, and the registration capacities affected (General Securities Principal, Financial Operations Principal, etc.):
If the individual received in the above action one or more suspensions from registration capacities, associations, and/or other activities, and the terms specify different time periods, report each in a separate entry.
(i) Duration (length of time):
Permanent (not limited by length of time). Temporary / Time Limited. Specify the
Days
Months
Years
(ii) Start Date (MM/DD/YYYY):
(iii) End Date (MM/DD/YYYY):
(iv) Description: Provide remaining details, including any explanation boxes checked above, and the registration capacities affected (General Securities Principal, Financial Operations Principal, etc.):
YES NO (a) Length of time given to requalify, retrain, or complete other process:
No time period is specified. Time period is specified: Months
Years
(b) Type of examination, retraining, or other process required:
(c) Was the condition satisfied?
If "Yes," provide the date (MM/DD/YYYY):
If "No," explain the circumstances:
(a) Total Amount Ordered:
(b) Portion levied against the individual:
(i) Amount Ordered :
(ii) Was any portion waived?
YES NO If "Yes," how much?
(iii) Final Amount:
(iv) Was final amount paid in full?
YES NO If "Yes," date paid in full:
If "No," explain the circumstances:
You may use this space to provide a brief summary of the circumstances leading to the action, allegation(s), finding(s) and disposition(s), if any. Include any relevant information on the current action status, and on any terms, conditions, and dates not already provided above, and any other relevant information. The information must fit within the space provided.
CUSTOMER COMPLAINT / ARBITRATION / CIVIL LITIGATION DISCLOSURE REPORTING PAGE (MA-I)
CUSTOMER COMPLAINT / ARBITRATION / CIVIL LITIGATION ACTION DRP – PART 1
This Disclosure Reporting Page (DRP MA-I) is an INITIAL or AMENDED response to report details for affirmative response(s) to Question(s) 6I on Form MA-I.
Check the question(s) to which this DRP pertains:
6I(1)(a) 6I(2)(a) 6I(2)(c) 6I(1)(b) 6I(2)(b) YES NO The event or proceeding was resolved in the individual's favor The DRP was filed in error.
Explain the circumstances:
How to Report a Matter or a Proceeding on this DRP: Use a separate DRP for each matter or proceeding. One matter may result in more than one affirmative answer to the above items. Use a single DRP to report details relating to a particular matter (i.e., a customer complaint, arbitration, CFTC reparation, or civil litigation). If an event gives rise to separate proceedings by more than one regulator or other authority, or other plaintiff, provide details for each proceeding on a separate DRP. Separate cases arising out of the same matter, and unrelated civil judicial actions, must be reported on separate DRPs; if they are later consolidated into a single civil judicial action, the consolidated action can be reported on one DRP.
YES NO Note: The filer may identify a DRP filed by the individual directly, or filed by another SEC-registrant about the individual as an associated person.
If the answer is "Yes," provide the applicable information indicated below that identifies where the DRP may be found.
NOTE: The completion of all or any part of this form does not relieve the individual or any municipal advisor with which the individual is associated of the obligation to update any relevant Form MA or IARD or CRD records.
Disclosure Instructions and the Individual's Status: You must indicate the individual's status in Items II and III below.
CUSTOMER COMPLAINT / ARBITRATION / CIVIL LITIGATION ACTION DRP – PART 2
A. Customer complaints, arbitrations / CFTC reparations and civil litigation in which the individual is not named as a party, as well as,
B. Arbitrations / CFTC reparations and civil litigation in which the individual is named as a party.
And complete Items 7-11. A. If the matter involves a customer complaint, or an arbitration / CFTC reparation or civil litigation in which the individual is not named as a party, complete Items 7-11 as appropriate.
B. If a customer complaint has evolved into an arbitration / CFTC reparation or civil litigation, amend the existing Disclosure Form by completing Items 9 and 10.
And check the appropriate boxes below: A. Arbitration / CFTC Reparation:
If the matter involves an arbitration / CFTC reparation in which the individual is a named party, check here And complete Items 12-16, as appropriate.
B. Civil Litigation: If the matter involves a civil litigation in which the individual is a named party, check here And complete Items 17-23.
This is an optional space and applies to all event types (i.e., customer complaint, arbitration/CFTC reparation, civil litigation).
Complete Items 1-6 for all matters (i.e., customer complaints, arbitrations/CFTC reparations, civil litigation).
YES NO Provide the full legal name of the individual's employing firm, if any, when activities occurred which led to the customer complaint, arbitration, CFTC reparation or civil litigation (if there was no such employing firm at that time, enter "None"). Enter the employing firm's MA and CRD registration numbers below, if any.
A. Employing Firm:
No Product Annuity-Charitable Direct Investment-DPP & LP Interest Oil & Gas Annuity-Fixed Equipment Leasing Options Annuity-Variable Equity Listed (Common & Preferred Stock) Penny Stock Banking Product (other than CD)
Equity-OTC Prime Bank Instrument Futures-Commodity Promissory Note CD Futures-Financial Real Estate Security Commodity Option Index Option Security Futures Debt-Asset Backed Insurance Security-based Swap Debt-Corporate Investment Contract Swap Debt-Government Money Market Fund Unit Investment Trust Debt-Municipal Mutual Fund Viatical Settlement Derivative Other Product Type? YES NO Describe the allegation(s) and provide a brief summary of events related to the allegation(s), including dates when activities leading to the allegation(s) occurred:
6. Alleged Compensatory Damage(s)
YES NO Exact Explanation
If not exact, provide explanation:
If the Individual Is Not a Named Party: If the matter involves a customer complaint, arbitration/CFTC reparation or civil litigation in which the individual is not named as a party, complete items 7-11 as appropriate.
If the Individual Is a Named Party: Report in Items 12-16, or 17-23, as appropriate, only arbitrations/CFTC reparations or civil litigation in which the individual is named as a party.
YES NO B. Is this a written complaint?
YES NO C. Is this an arbitration/CFTC reparation or civil litigation?
YES NO If "Yes," provide:
(1) Arbitration/reparation forum or court name:
(2) Location of the Forum or Court:
Street Address:
City or County:
State / Country:
Postal Code:
(3) Docket/Case Name:
(4) Docket/Case Number:
(5) Filing date of arbitration/CFTC reparation or civil litigation (MM/DD/YYYY):
D. Date received by/served on firm (MM/DD/YYYY):
Exact Explanation If not exact, provide explanation:
Is the complaint, arbitration/CFTC reparation or civil litigation pending?
YES NO If "No," complete item 9.
If the complaint, arbitration/CFTC reparation or civil litigation is not pending, provide status:
Closed/No Action Withdrawn Denied Settled Arbitration Award/Monetary Judgment (for claimants/plaintiffs) Arbitration Award/Monetary Judgment (for respondents/defendants) Evolved into Arbitration/CFTC reparation (the individual is a named party): Complete Items 12-16. Evolved into Civil litigation (you are a named party): Complete Items 17-23.Status:
If the Individual Is Not a Named Party: If the status is arbitration/CFTC reparation in which the individual is not a named party, provide details in Item 7C.
If the Individual Is a Named Party: If the status is arbitration/CFTC reparation in which the individual is a named party, complete Items 12-16. If the status is civil litigation in which the individual is a named party, complete Items 17-23.
10. Status Date (MM/DD/YYYY):
Exact Explanation A. Is there a Settlement/Award/Monetary Judgment?
YES NO If "Yes," provide the details below.
B. Settlement/Award/Monetary Judgment Amount:
C. Was the individual required to pay any portion of the total amount?
YES NO If "Yes," indicate:
(1) The individual's contribution amount:
(2) Was any portion waived?
YES NO If "Yes," how much?
(3) Final Amount:
(4) Was final amount paid in full?
YES NO If "Yes," date paid in full:
If "No," explain the circumstances:
If the matter involves an arbitration or CFTC reparation in which the individual is a named respondent, complete Items 12-16, as appropriate.
B. Location of the Forum
C. Docket/Case Name:
D. Docket/Case Number:
E. Date notice/process was served (MM/DD/YYYY):
Exact Explanation If not exact, provide explanation:
YES NO If "No," complete Items 14 and 15.
Award to the Individual (Agent/Representative) Award to Customer Denied Dismissed Judgment (other than monetary) No Action Settlement that includes a monetary payment to customer Settlement without a monetary payment to customer Withdrawn Other (specify) Exact Explanation If not exact, provide explanation:
(If you checked "Award to Customer," or "Settlement that includes a monetary payment to customer" in Item 14 or otherwise a payment of money must be made to the customer, provide the following information.)
A. Total Amount:
B. The Individual's Portion: Was the individual required to pay any portion of the total amount?
YES NO C. If you answered "Yes," to Item 16-B, indicate:
(1) The individual's contribution amount:
(2) Was any portion waived?
YES NO If "Yes," how much?
(3) Final Amount:
(4) Was final amount paid in full?
YES NO If "Yes," date paid in full:
If "No," explain the circumstances:
If the matter involves a civil litigation in which the individual is a defendant, complete items 17-23.
Federal Court Military Court State Court Foreign Court International Court Other (specify) A. Name of the Court:
B. Location of the Court
Street Address:
City or County:
State/Country:
Postal Code:
C. Docket/Case Name:
D. Docket/Case Number :
Exact Explanation If not exact, provide explanation:
Pending (Skip to Item 24.) On Appeal (Complete Items 20-23; and consider Item 24.) Final (Complete Items 20-22; and Item 23 if applicable; and consider Item 24.) Denied Dismissed Judgment (other than monetary) Monetary Judgment to the Individual (Agent/Representative) Monetary Judgment to Customer No Action Settlement that includes a monetary payment to customer Settlement without a monetary payment to customer Withdrawn Other (specify) Exact Explanation If not exact, provide explanation:
22. Monetary Compensation Details
(If you checked "Monetary Judgment to Customer" or "Settlement that includes a monetary payment to customer" in Item 20, or otherwise a payment of money must be made to the customer, provide the following information.)
A. Total Amount:
B. Was the individual required to pay any portion of the total amount?
YES NO C. If you answered "Yes," to Item 22-B, indicate:
(1) The individual's contribution amount:
(2) Was any portion waived?
YES NO If "Yes," how much?
(3) Final Amount:
(4) Was final amount paid in full?
YES NO If "Yes," date paid in full:
If "No," explain the circumstances:
23. On Appeal - Judicial Review:
If the individual appealed, provide the following information. (If brought in a foreign jurisdiction, provide all the information below in English):
A. Action Appealed to:
(Provide the name of the federal, military, state, foreign, or international court to which the individual appealed):
B. Location of the Court:
Street Address:
City or County:
State/Country:
Postal Code:
C. Docket/Case Name:
D. Docket/Case Number:
E. Date Appeal filed (MM/DD/YYYY)
Exact Explanation If not exact, provide explanation:
F. Appeal Details (including status):
You may use this space to provide a brief summary of the circumstances leading to the customer complaint, arbitration/CFTC reparation and/or civil litigation as well as the current status or final disposition(s). The information must fit within the space provided.