Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: NOTICE TO THE INDIVIDUAL WHO IS THE SUBJECT OF THIS FILING Even if you are no longer registered you continue to be subject to the jurisdiction of regulators for at least two years after your registration is terminated and may have to provide information about your activities while associated with this firm. Therefore, you must forward any residential address changes for two years following your termination date or last Form U5 amendment to: CRD Address Changes, P.O. Box 9495, Gaithersburg, MD 20898-9495. 1. GENERAL INFORMATION FIRST NAME: MIDDLE NAME: FIRM CRD #: FIRM NAME: INDIVIDUAL CRD #: INDIVIDUAL SSN: LAST NAME: SUFFIX: FIRM NFA#: INDIVIDUAL NFA#: FIRM Billing Code: Office of Employment Address: Registered Non-Registered CRD BRANCH #: NYSE BRANCH CODE #: FIRM BILLING CODE: Located At Supervised From START DATE: END DATE: OFFICE OF EMPLOYMENT ADDRESS STREET 1: CITY: STATE: OFFICE OF EMPLOYMENT ADDRESS STREET 2: COUNTRY: POSTAL CODE: Private Residence Check Box: If the Office of Employment address is a private residence, check this box. Registered Non-Registered CRD BRANCH #: NYSE BRANCH CODE #: FIRM BILLING CODE: Located At Supervised From START DATE: END DATE: OFFICE OF EMPLOYMENT ADDRESS STREET 1: CITY: STATE: OFFICE OF EMPLOYMENT ADDRESS STREET 2: COUNTRY: POSTAL CODE: Private Residence Check Box: If the Office of Employment address is a private residence, check this box. Registered Non-Registered CRD BRANCH #: NYSE BRANCH CODE #: FIRM BILLING CODE: Located At Supervised From START DATE: END DATE: OFFICE OF EMPLOYMENT ADDRESS STREET 1: CITY: STATE: OFFICE OF EMPLOYMENT ADDRESS STREET 2: COUNTRY: POSTAL CODE: Private Residence Check Box: If the Office of Employment address is a private residence, check this box. 2. CURRENT RESIDENTIAL ADDRESS NOTICE TO THE FIRM: This is the last reported residential address. If this is not current, please enter the current residential address. FROM (MM/YYYY): TO (MM/YYYY): ADDRESS STREET 1: CITY: STATE: ADDRESS STREET 2: COUNTRY: POSTAL CODE: Page 1 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: 3. FULL TERMINATION Is this a FULL TERMINATION? Yes No Note: A "Yes" response will terminate ALL registrations with all SROs and all jurisdictions. Reason For Termination: Discharged Other Permitted to Resign Deceased Voluntary Termination Explanation: If the Reason for Termination entered above is Permitted to Resign, Discharged or Other, provide an explanation below: If amending the Reason for Termination and/or termination explanation, provide an explanation below: 4. DATE OF TERMINATION Date Terminated (MM/DD/YYYY): _______________________________ A complete date of termination is required for full termination. This date represents the date the firm terminated the individual's association with the firm in a capacity for which registration is required. For partial termination, the date of termination is only applicable to post-dated termination requests during the renewal period. Notes: For full termination, this date is used by jurisdictions/SROs to determine whether an individual is required to requalify by examination or obtain an appropriate waiver upon reassociating with another firm. The SRO/jurisdiction determines the effective date of termination of registration. If amending the Date of Termination, provide an explanation below: Page 2 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: 5. PARTIAL TERMINATION For a partial termination, do not complete the Reason for Termination in Section 3 (FULL TERMINATION) or Section 7 (DISCLOSURE QUESTIONS). The Reason for Termination and Section 7 (DISCLOSURE QUESTIONS) should only be completed on Form U5 for full termination requests. 5A. SRO PARTIAL TERMINATION If this is a PARTIAL TERMINATION, mark the appropriate SRO registration categories to be terminated. REGISTRATION CATEGORY FINRA NYSE AMEX BATS BX NSX ARCA CBOE CHX PHLX ISE NQX OP - Registered Options Principal (S4) IR - Investment Company and Variable Contracts Products Rep. (S6) GS - Full Registration/General Securities Representative (S7) TR - Securities Trader (S7) TS - Trading Supervisor (S7) SU - General Securities Sales Supervisor (S9 and S10) BM - Branch Office Manager (S9 and S10) SM - Securities Manager (S10) AR - Assistant Representative/Order Processing (S11) IE - United Kingdom - Limited General Securities Registered Representative (S17) DR - Direct Participation Program Representative (S22) GP - General Securities Principal (S24) IP - Investment Company and Variable Contracts Products Principal (S26) FA - Foreign Associate FN - Financial and Operations Principal (S27) FI - Introducing Broker-Dealer/Financial and Operations Principal (S28) RS - Research Analyst (S86, S87) RP - Research Principal DP - Direct Participation Program Principal (S39) OR - Options Representative (S42) MR - Municipal Securities Representative (S52) MP - Municipal Securities Principal (S53) CS - Corporate Securities Representative (S62) RG - Government Securities Representative (S72) PG - Government Securities Principal (S73) SA - Supervisory Analyst (S16) PR - Limited Representative - Private Securities Offerings (S82) CD - Canada-Limited General Securities Registered Representative (S37) CN - Canada-Limited General Securities Registered Representative (S38) ET - Equity Trader (S55) AM - Allied Member AP - Approved Person LE - Securities Lending Representative LS - Securities Lending Supervisor ME - Member Exchange FE - Floor Employee OF - Officer CO - Compliance Official (S14) CF - Compliance Official Specialist (S14A) PM - Floor Member Conducting Public Business PC - Floor Clerk Conducting Public Business SC - Specialist Clerk (S21) TA - Trading Assistant (S25) FP - Municipal Fund (S51) IF - In-Firm Delivery Proctor MM - Market Maker Authorized Trader-Options (S44) FB - Floor Broker MB - Market Maker acting as Floor Broker OT - Authorized Trader (S7) MT - Market Maker Authorized Trader-Equities (S7) Other__________________________________ (Paper Form Only) Page 3 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: 5B. JURISDICTION PARTIAL TERMINATION Check appropriate jurisdiction(s) for broker-dealer agent (AG) and/or investment adviser representative (RA) termination. JURISDICTION Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho AG RA JURISDICTION Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri AG RA JURISDICTION Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania AG RA JURISDICTION Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming AG RA AGENT OF THE ISSUER REGISTRATION (AI) Indicate 2 letter jurisdiction code(s):___________ 6. AFFILIATED FIRM TERMINATION Is this a multiple termination with one or more firms affiliated with the filing firm? Yes No If "yes" to the above question and the termination requests for the filing firm are identical to the termination requests of each affiliated firm, then mark the same termination request for each affiliate. If the termination requests of the affiliated firm(s) differ from those of the filing firm, complete the SRO and/or jurisdiction sections for each affiliated firm. AFFILIATED FIRM CRD #: AFFILIATED FIRM NAME: AFFILIATED FIRM BILLING CODE: Office of Employment Address: Registered Non-Registered CRD BRANCH #: NYSE BRANCH CODE #: FIRM BILLING CODE: Located At Supervised From START DATE: END DATE: OFFICE OF EMPLOYMENT ADDRESS STREET 1: CITY: STATE: OFFICE OF EMPLOYMENT ADDRESS STREET 2: COUNTRY: POSTAL CODE: Private Residence Check Box: If the Office of Employment address is a private residence, check this box. Registered Non-Registered CRD BRANCH #: NYSE BRANCH CODE #: FIRM BILLING CODE: Located At Supervised From START DATE: END DATE: OFFICE OF EMPLOYMENT ADDRESS STREET 1: CITY: STATE: OFFICE OF EMPLOYMENT ADDRESS STREET 2: COUNTRY: POSTAL CODE: Private Residence Check Box: If the Office of Employment address is a private residence, check this box. Registered Non-Registered CRD BRANCH #: NYSE BRANCH CODE #: FIRM BILLING CODE: Located At Supervised From START DATE: END DATE: OFFICE OF EMPLOYMENT ADDRESS STREET 1: CITY: STATE: OFFICE OF EMPLOYMENT ADDRESS STREET 2: COUNTRY: POSTAL CODE: Private Residence Check Box: If the Office of Employment address is a private residence, check this box. Page 4 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: 7. DISCLOSURE QUESTIONS IF THE ANSWER TO ANY OF THE FOLLOWING QUESTIONS IN SECTION 7 IS 'YES', COMPLETE DETAILS OF ALL EVENTS OR PROCEEDINGS ON APPROPRIATE DRP(s). IF THE INFORMATION IN SECTION 7 HAS ALREADY BEEN REPORTED ON FORM U4 OR FORM U5, DO NOT RESUBMIT DRPs FOR THESE ITEMS. REFER TO THE EXPLANATION OF TERMS SECTION OF FORM U5 INSTRUCTIONS FOR EXPLANATION OF ITALICIZED WORDS. Disclosure Certification Checkbox (optional): By selecting the Disclosure Certification Checkbox, the firm certifies that (1) there is no additional information to be reported at this time; (2) details relating to Questions 7A, 7C, 7D and 7E have been previously reported on behalf of the individual via Form U4 and/or amendments to Form U4 (if applicable); and (3) updated information will be provided, if needed, as it becomes available to the firm. Note: Use of “Disclosure Certification Checkbox” is optional. Yes 7A. No Investigation Disclosure Currently is, or at termination was, the individual the subject of an investigation or proceeding by a domestic or foreign governmental body or self-regulatory organization with jurisdiction over investment-related businesses? (Note: Provide details of an investigation on an Investigation Disclosure Reporting Page and details regarding a proceeding on a Regulatory Action Disclosure Reporting Page.) Internal Review Disclosure 7B. Currently is, or at termination was, the individual under internal review for fraud or wrongful taking of property, or violating investment-related statutes, regulations, rules or industry standards of conduct? 7C. While employed by or associated with your firm, or in connection with events that occurred while the individual was employed by or associated with your firm, was the individual: 1. convicted of or did the individual plead guilty or nolo contendere ("no contest") in a domestic, foreign or military court to any felony? 2. charged with any felony? 3. convicted of or did the individual plead guilty or nolo contendere ("no contest") in a domestic, foreign or military court to a misdemeanor involving: investments or an 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? 4. charged with a misdemeanor specified in item 7(C)(3)? Criminal Disclosure Regulatory Action Disclosure 7D. While employed by or associated with your firm, or in connection with events that occurred while the individual was employed by or associated with your firm, was the individual involved in any disciplinary action by a domestic or foreign governmental body or self-regulatory organization (other than those designated as a "minor rule violation" under a plan approved by the U.S. Securities and Exchange Commission) with jurisdiction over the investment-related businesses? Customer Complaint/Arbitration/Civil Litigation Disclosure 7E. 1. In connection with events that occurred while the individual was employed by or associated with your firm, was the individual named as a respondent/defendant in an investment-related, consumer-initiated arbitration or civil litigation which alleged that the individual was involved in one or more sales practice violations and which: (a) is still pending, or; (b) resulted in an arbitration award or civil judgment against the individual, regardless of amount, or; (c) was settled, prior to 05/18/2009, for an amount of $10,000 or more, or; (d) was settled, on or after 05/18/2009, for an amount of $15,000 or more? 2. In connection with events that occurred while the individual was employed by or associated with your firm, was the individual the subject of an investment-related, consumer-initiated (written or oral) complaint, which alleged that the individual was involved in one or more sales practice violations, and which (a) was settled, prior to 05/18/2009, for an amount of $10,000 or more, or; (b) was settled, on or after 05/18/2009, for an amount of $15,000 or more? Page 5 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: 7. DISCLOSURE QUESTIONS (CONTINUED) Yes No 3. In connection with events that occurred while the individual was employed by or associated with your firm, was the individual the subject of an investment-related, consumer-initiated, written complaint, not otherwise reported under question 7(E)(2) above, which: (a) would be reportable under question 14I(3)(a) on Form U4, if the individual were still employed by your firm, but which has not previously been reported on the individual's Form U4 by your firm; or (b) would be reportable under question 14I(3)(b) on Form U4, if the individual were still employed by your firm, but which has not previously been reported on the individual's Form U4 by your firm. Answer questions (4) and (5) below only for arbitration claims or civil litigation filed on or after 05/18/2009. 4. In connection with events that occurred while the individual was employed by or associated with your firm, was the individual the subject of an investment-related, consumer-initiated, arbitration claim or civil litigation which alleged that the individual was involved in one or more sales practice violations, and which: (a) was settled for an amount of $15,000 or more, or; (b) resulted in an arbitration award or civil judgment against any named respondent(s)/defendant(s), regardless of amount? 5. In connection with events that occurred while the individual was employed by or associated with your firm, was the individual the subject of an investment-related, consumer-initiated, arbitration claim or civil litigation not otherwise reported under question 7E(4) above, which: (a) would be reportable under question 14I(5)(a) on Form U4, if the individual were still employed by your firm, but which has not previously been reported on the individual’s Form U4 by your firm; or (b) would be reportable under question 14I(5)(b) on Form U4, if the individual were still employed by your firm, but which has not previously been reported on the individual's Form U4 by your firm. Termination Disclosure 7F. Did the individual voluntarily resign from your firm, or was the individual discharged or permitted to resign from your firm, after allegations were made that accused the individual of: 1. violating investment-related statutes, regulations, rules or industry standards of conduct? 2. fraud or the wrongful taking of property? 3. failure to supervise in connection with investment-related statutes, regulations, rules or industry standards of conduct? 8. SIGNATURE Please Read Carefully All signatures required on this Form U5 filing must be made in this section. A "Signature" includes a manual signature or an electronically transmitted equivalent. For purposes of an electronic form filing, a signature is effected by typing a name in the designated signature field. By typing a name in this field, the signatory acknowledges and represents that the entry constitutes in every way, use, or aspect, his or her legally binding signature. 8A. FIRM ACKNOWLEDGMENT This section must be completed on all U5 form filings submitted by the firm. 8B. INDIVIDUAL ACKNOWLEDGMENT AND CONSENT This section must be completed on amendment U5 form filings where the individual is submitting changes to Part II of the INTERNAL REVIEW DRP or changes to Section 2 (CURRENT RESIDENTIAL ADDRESS). 8A. FIRM ACKNOWLEDGMENT I VERIFY THE ACCURACY AND COMPLETENESS OF THE INFORMATION CONTAINED IN AND WITH THIS FORM. __________________________________________________ Person to contact for further information _______________________________________________________ Telephone # of person to contact __________________________________________________ Signature of Appropriate Signatory _______________________________________________________ Date (MM/DD/YYYY) __________________________________________________ Type or Print Name of Appropriate Signatory Page 6 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: 8B. INDIVIDUAL ACKNOWLEDGMENT AND CONSENT I VERIFY THE ACCURACY AND COMPLETENESS OF THE INFORMATION CONTAINED IN SECTION 2 (CURRENT RESIDENTIAL ADDRESS) AND/OR IN PART II OF THE INTERNAL REVIEW DRP. __________________________________________________ Individual Signature _______________________________________________________ Date (MM/DD/YYYY) __________________________________________________ Type or Print Name of Individual Page 7 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: DISCLOSURE REPORTING PAGES U5 - CRIMINAL DRP This Disclosure Reporting Page is an on Form U5; INITIAL or Rev. DRP (05/2009) AMENDED response to report details for affirmative response(s) to Question(s) 7C Check the question(s) you are responding to, regardless of whether you are answering the question(s) "yes" or amending the answer(s) to "no": 7C(1) 7C(2) 7C(3) 7C(4) Use this DRP to report all charges arising out of the same event. One event may result in more than one affirmative answer to the above items. Multiple counts of the same charge arising out of the same event should be reported on the same DRP. Unrelated criminal actions, including separate cases arising out of the same event, must be reported on separate DRPs. Applicable court documents (i.e., criminal complaint, information or indictment as well as judgment of conviction or sentencing documents) must be provided to the CRD if not previously submitted. 1. Formal action was brought in: Federal Court State Court Military Court Foreign Court Other:________________________ A. Name of Court:____________________________________________________________ B. Location of Court (City or County and State or Country):______________________________________________________________ C. Docket/Case#:______________ 2. Event Status: A. Current status of the Event? Pending On Appeal Final B. Event Status Date (complete unless status is pending) (MM/DD/YYYY):_________________ If not exact, provide explanation: Exact Explanation 3. Event and Disposition Disclosure Detail (Use this for both organizational and individual charges.): A. Date First Charged (MM/DD/YYYY):___________________________ Exact Explanation If not exact, provide explanation: B. Event and Disposition Detail: Charge Details (complete every field for each charge.) Formal Charge/Description: No. of Counts:________ Felony or Misdemeanor: Felony Misdemeanor Plea for each Charge:__________________________________________ Disposition of Charge: Acquitted Dismissed Amended Found not guilty Convicted Pled guilty Deferred Adjudication Pled not guilty Pre-trial Intervention Reduced Other (requires explanation) Explanation: Date of Amended Charge, if applicable:_________________ Page 8 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: Rev. DRP (05/2009) U5 - CRIMINAL DRP (CONTINUED) If original charge was amended or reduced, specify new charge (i.e., list amended charge or reduced charge): No. of Counts (for amended or reduced charge):________ Felony Misdemeanor Specify if amended or reduced charge is a Felony or Misdemeanor: Plea for each amended or reduced charge:__________________________________________ Disposition of amended or reduced charge: Acquitted Dismissed Amended Found not guilty Convicted Pled guilty Deferred Adjudication Pled not guilty Other:_________________ Pre-trial Intervention Reduced Other (requires explanation) Explanation: Charge Details (complete every field for each charge.) Formal Charge/Description: No. of Counts:________ Felony or Misdemeanor: Felony Misdemeanor Plea for each Charge:__________________________________________ Disposition of Charge: Acquitted Dismissed Amended Found not guilty Convicted Pled guilty Deferred Adjudication Pled not guilty Pre-trial Intervention Reduced Other (requires explanation) Explanation: Date of Amended Charge, if applicable:_________________ If original charge was amended or reduced, specify new charge (i.e., list amended charge or reduced charge): No. of Counts (for amended or reduced charge):________ Specify if amended or reduced charge is a Felony or Misdemeanor: Felony Misdemeanor Plea for each amended or reduced charge:__________________________________________ Disposition of amended or reduced charge: Acquitted Dismissed Amended Found not guilty Convicted Pled guilty Deferred Adjudication Pled not guilty Other:_________________ Pre-trial Intervention Reduced Other (requires explanation) Explanation: Page 9 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: Rev. DRP (05/2009) U5 - CRIMINAL DRP (CONTINUED) Charge Details (complete every field for each charge.) Formal Charge/Description: No. of Counts:________ Felony or Misdemeanor: Felony Misdemeanor Plea for each Charge:__________________________________________ Disposition of Charge: Acquitted Dismissed Amended Found not guilty Convicted Pled guilty Deferred Adjudication Pled not guilty Pre-trial Intervention Reduced Other (requires explanation) Explanation: Date of Amended Charge, if applicable:_________________ If original charge was amended or reduced, specify new charge (i.e., list amended charge or reduced charge): No. of Counts (for amended or reduced charge):________ Specify if amended or reduced charge is a Felony or Misdemeanor: Felony Misdemeanor Plea for each amended or reduced charge:__________________________________________ Disposition of amended or reduced charge: Acquitted Dismissed Amended Found not guilty Convicted Pled guilty Deferred Adjudication Pled not guilty Other:_________________ Pre-trial Intervention Reduced Other (requires explanation) Explanation: C. Date of Disposition (MM/DD/YYYY):___________________________ If not exact, provide explanation: Exact Explanation D. Sentence/Penalty; Duration (if suspension, probation, etc): Start Date of Penalty: (MM/DD/YYYY); End date of Penalty: (MM/DD/YYYY); If Monetary penalty/fine - Amount paid; Date monetary/penalty fine paid: (MM/DD/YYYY) if not exact, provide explanation. 4. Comment (Optional). You may use this field to provide a brief summary of the circumstances leading to the charge(s) as well as the current status or final disposition. Your information must fit within the space provided. Page 10 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: U5 - CUSTOMER COMPLAINT/ARBITRATION/CIVIL LITIGATION DRP This Disclosure Reporting Page is an Form U5; INITIAL or Rev. DRP (05/2009) AMENDED response to report details for affirmative response(s) to Question(s) 7E on Check the question(s) you are responding to, regardless of whether you are answering the question(s) "yes" or amending the answer(s) to "no": 7E(1)(a) 7E(2)(a) 7E(3)(a) 7E(4)(a) 7E(5)(a) 7E(1)(b) 7E(2)(b) 7E(3)(b) 7E(4)(b) 7E(5)(b) 7E(1)(c) 7E(1)(d) 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/civil litigation). Use a separate DRP for each matter. DRP Instructions: Complete items 1-6 for all matters (i.e., customer complaints, arbitrations/CFTC reparations and civil litigation in which a customer alleges that the individual was involved in sales practice violations and the individual is not named as a party, as well as arbitrations/CFTC reparations and civil litigation in which the individual is named as a party). If the matter involves a customer complaint, or an arbitration/CFTC reparation or civil litigation in which a customer alleges that the individual was involved in sales practice violations and the individual is not named as a party, complete items 7-11 as appropriate. If a customer complaint has evolved into an arbitration/CFTC reparation or civil litigation, amend the existing DRP by completing items 9 and 10 . If the matter involves an arbitration/CFTC reparation in which the individual is a named party, complete items 12-16, as appropriate. If the matter involves a civil litigation in which the individual is a named party, complete items 17-23. Item 24 is an optional field 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). 1. Customer Name(s):________________________________________________________________________________________ 2. A. Customer(s) State of Residence (select "not on list" when the customer's residence is a foreign address):______________________________________ B. Other state(s) of residence/detail: 3. Employing Firm when activities occurred which led to the customer complaint, arbitration, CFTC reparation or civil litigation: 4. Allegation(s) and a brief summary of events related to the allegation(s) including dates when activities leading to the allegation(s) occurred: 5. Product Type(s): (select all that apply) No Product Annuity-Charitable Annuity-Fixed Annuity-Variable Banking Product (other than CD) CD Commodity Option Debt-Asset Backed Debt-Corporate Debt-Government Debt-Municipal Derivative Direct Investment-DPP & LP Interest Equipment Leasing Equity Listed (Common & Preferred Stock) Equity-OTC Futures Commodity Futures-Financial Index Option Insurance Investment Contract Money Market Fund Mutual Fund Oil & Gas Options Penny Stock Prime Bank Instrument Promissory Note Real Estate Security Security Futures Unit Investment Trust Viatical Settlement Other:______________________ 6. Alleged Compensatory Damage Amount:______________________ Exact Explanation (If no damage amount is alleged, the complaint must be reported unless the firm has made a good faith determination that the damages from the alleged conduct would be less than $5,000): Page 11 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: U5 - CUSTOMER COMPLAINT/ARBITRATION/CIVIL LITIGATION DRP (CONTINUED) Rev. DRP (05/2009) If the matter involves a customer complaint, arbitration/CFTC reparation or civil litigation in which a customer alleges that the individual was involved in sales practice violations and the individual is not named as a party, complete items 7-11 as appropriate. Note: 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. 7. A. Is this an oral complaint? Yes No Yes No B. Is this an written complaint? C. Is this an arbitration/CFTC reparation or civil litigation? Yes No If yes, provide: i. Arbitration/reparation forum or court name and location:___________________________________________________________ ii. Docket/Case#:______________________________ iii. Filing date of arbitration/CFTC reparation or civil litigation (MM/DD/YYYY):_______________ D. Date received by/served on firm (MM/DD/YYYY):_______________ If not exact, provide explanation: Exact 8. Is the complaint, arbitration/CFTC reparation or civil litigation pending? If "No", complete item 9. Yes Explanation No 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) Evolved into Civil litigation (the individual is a named party) If status is arbitration/CFTC reparation in which the individual is not a named party, provide details in item 7C. If status is arbitration/CFTC reparation in which the individual is a named party, complete items 12-16. If status is civil litigation in which the individual is a named party, complete items 17-23. 10. Status Date (MM/DD/YYYY):_______________ If not exact, provide explanation: Exact Explanation 11. Settlement/Award/Monetary Judgment: A. Settlement/Award/Monetary Judgment amount: $_________________ B. Individual Contribution Amount: $_________________ If the matter involves an arbitration or CFTC reparation in which the individual is a named respondent, complete items 12-16, as appropriate. 12. A. Arbitration/CFTC reparation claim filed with (FINRA, AAA, CFTC, etc.):________________________________________________ B. Docket/Case#:______________________________ C. Date notice/process was served (MM/DD/YYYY):_______________ Exact Explanation If not exact, provide explanation: 13. Is arbitration/ CFTC reparation pending? If "No", complete item 14. Yes No 14. If the arbitration/CFTC reparation is not pending, what was the disposition? Award to Applicant (Agent/Representative) Judgment (other than monetary) Award to Customer No Action Denied Settled Dismissed Withdrawn Other:______________________________ 15. Disposition Date (MM/DD/YYYY):_______________ If not exact, provide explanation: Exact Explanation Page 12 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: Rev. DRP (05/2009) U5 - CUSTOMER COMPLAINT/ARBITRATION/CIVIL LITIGATION DRP (CONTINUED) 16. Monetary Compensation Details (award, settlement, reparation amount): A. Total Amount: $_________________ B. Individual Contribution Amount: $_________________ If the matter involves a civil litigation in which the individual is a defendant, complete items 17-23. 17. Court in which case was filed: Federal Court State Court Foreign Court Military Court Other:_________________________________ A. Name of Court:____________________________________________________________________ B. Location of Court (City or County and State or Country):___________________________________________________________ C. Docket/Case#:______________ 18. Date notice/process was served (MM/DD/YYYY):_______________ If not exact, provide explanation: 19. Is the civil litigation pending? If "No", complete item 20. Yes Exact Explanation No 20. If the civil litigation is not pending, what was the disposition? Denied Dismissed Monetary Judgment to Applicant (Agent/Representative) No Action Settled Other:______________________________ 21. Disposition Date (MM/DD/YYYY):_______________ If not exact, provide explanation: Exact Judgment (other than monetary) Monetary Judgment to Customer Withdrawn Explanation 22. Monetary Compensation Details (judgment, restitution, settlement amount): A. Total Amount: $_________________ B. Individual Contribution Amount: $_________________ 23. If action is currently on appeal: A. Enter date appeal filed (MM/DD/YYYY):_______________ If not exact, provide explanation: Exact Explanation B. Court appeal filed in: Federal Court State Court Foreign Court Military Court Other:_________________________________ i. Name of Court:____________________________________________________________________ ii. Location of Court (City or County and State or Country):___________________________________________________________ iii. Docket/Case#:______________ 24. Comment (Optional). You may use this field 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). Your information must fit within the space provided. Page 13 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: Rev. DRP (05/2009) U5 - INTERNAL REVIEW DRP This Disclosure Reporting Page is an on Form U5; INITIAL or AMENDED response to report details for affirmative response(s) to Question(s) 7B Check the question(s) you are responding to, regardless of whether you are answering the question(s) "yes" or amending the answer(s) to "no": 7B If the individual has been notified that the internal review has been concluded without formal action, complete items 4 and 5 of this DRP to update. PART I 1. Notice Received From (Name of firm initiating the internal review):________________________________________ 2. Date internal review initiated (MM/DD/YYYY):________________________________ If not exact, provide explanation: Exact Explanation 3. Describe briefly the nature of the internal review. (The information must fit within the space provided): 4. Is internal review pending? Yes No If no, complete item 5. If yes, skip to item 6. 5. Resolution Details: A. Date internal review concluded (MM/DD/YYYY):________________________________ If not exact, provide explanation: Exact Explanation B. How was internal review concluded (provide details of the conclusion)? 6. Comment (Optional). You may use this field to provide a brief summary of the circumstances leading to the action, as well as the current status or final disposition. Your information must fit within the space provided. PART II INDIVIDUAL SUBJECT MAY USE THIS SPACE FOR DETAILS TO AFFIRMATIVE ANSWERS OF ITEM 7(B) ONLY The individual who is the subject of the internal review may provide a brief summary of this event limited to 4000 characters. The summary may be submitted electronically to the Registration and Disclosure Department by the terminating firm or may be sent via hard copy to: Registration and Disclosure FINRA P.O. Box 9495 Gaithersburg, MD 20898-9495 Note: Section 8B. INDIVIDUAL ACKNOWLEDGEMENT AND CONSENT of the Form U5 requires individuals to verify the accuracy and completeness of the information in Part II of the Internal Review DRP. An executed (i.e. signed and dated) acknowledgement and consent must be submitted with the summary. Page 14 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: U5 - INVESTIGATION DRP Rev. DRP (05/2009) INITIAL or AMENDED response to report details for affirmative response(s) to Question(s) 7A on This Disclosure Reporting Page is an Form U5; Check the question(s) you are responding to, regardless of whether you are answering the question(s) "yes" or amending the answer(s) to "no": 7A Complete this DRP only if you are answering "yes" to Item 7(A) to report an investigation. Complete a Regulatory Action DRP if you answered "yes" to item 7(A) and are reporting details of either a pending or final proceeding. If you have been notified that the investigation has been concluded without formal action, complete items 4 and 5 of this DRP to update. One event may result in more than one investigation. If more than one authority is investigating, use a separate DRP to provide details. 1. Investigation initiated by: A. Notice Received From (select appropriate item): SRO Foreign Financial Regulatory Authority Jurisdiction SEC Other Federal Agency Other:_________________________________ B. Full name of regulator (if other than the SEC) that initiated the investigation:__________________________________________ 2. Notice Date (MM/DD/YYYY):________________________________ If not exact, provide explanation: Exact Explanation 3. Describe briefly the nature of the investigation, if known. (Your information must fit within the space provided.): 4. Is investigation pending? Yes If no, complete item 5. If yes, skip to item 6. No 5. Resolution Details: A. Date Closed/Resolved (MM/DD/YYYY):________________________________ If not exact, provide explanation: B. How was investigation resolved? (select appropriate item): Closed Without Further Action Closed - Regulatory Action Initiated Exact Explanation Other:_________________________________ 6. Comment (Optional). You may use this field to provide a brief summary of the circumstances leading to the investigation, as well as the current status or final disposition and/or finding(s). Your information must fit within the space provided. Page 15 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: Rev. DRP (05/2009) U5 - REGULATORY ACTION DRP This Disclosure Reporting Page is an and 7D on Form U5; INITIAL or AMENDED response to report details for affirmative response(s) to Question(s) 7A Check the question(s) you are responding to, regardless of whether you are answering the question(s) "yes" or amending the answer(s) to "no": 7A 7D One event may result in more than one affirmative answer to the above items. Use only one DRP to report details to the same event. If an event gives rise to actions by more than one regulator, provide details to each action on a separate DRP. 1. Regulatory Action initiated by: A. (Select appropriate item): SEC Other Federal Agency Federal Banking Agency Jurisdiction SRO CFTC National Credit Union Administration Foreign Financial Regulatory Authority Other:_______________________________ B. Full name of regulator (if other than the SEC) that initiated the action:_________________________________________________ 2. Sanction(s) Sought (select all that apply): Bar Civil and Administrative Penalty(ies)/Fine(s) Expulsion Reprimand Restitution Undertaking Cease and Desist Denial Monetary Penalty other than Fines Requalification Revocation Other:_______________________________ 3. Date Initiated (MM/DD/YYYY):_____________________ If not exact, provide explanation: Exact Censure Disgorgement Prohibition Rescission Suspension Explanation 4. Docket/Case #:________________________________________________ 5. Employing Firm when activity occurred which led to the regulatory action:________________________________________________ 6. Product Type(s) (select all that apply): No Product Annuity-Charitable Annuity-Fixed Annuity-Variable Banking Product (other than CD) CD Commodity Option Debt-Asset Backed Debt-Corporate Debt-Government Debt-Municipal Derivative Direct Investment-DPP & LP Interest Equipment Leasing Equity Listed (Common & Preferred Stock) Equity-OTC Futures Commodity Futures-Financial Index Option Insurance Investment Contract Money Market Fund Mutual Fund Oil & Gas Options Penny Stock Prime Bank Instrument Promissory Note Real Estate Security Security Futures Unit Investment Trust Viatical Settlement Other:________________________ 7. Describe the allegations related to this regulatory action. (Your information must fit within the space provided.): 8. Current Status? Pending On Appeal Final 9. If pending, are there any limitations or restrictions currently in effect? If the answer is 'yes', provide details: Yes No Page 16 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: Rev. DRP (05/2009) U5 - REGULATORY ACTION DRP (CONTINUED) 10. If on appeal: A. Action appealed to: SEC SRO CFTC Federal Court State Agency or Commission State Court Other:_________________________________ B. Date appeal filed (MM/DD/YYYY):_____________________ Exact Explanation If not exact, provide explanation: C. Are there any limitations or restrictions currently in effect while on appeal? If the answer is 'yes', provide details: Yes No If Final or On Appeal, complete all items below. For Pending Actions, complete Item 13 only. 11. Resolution Detail: A. How was matter resolved? (select appropriate item): Acceptance, Waiver & Consent (AWC) Consent Decision & Order of Offer of Settlement Dismissed Settled Stipulation and Consent Vacated Nunc Pro Tunc/ab initio Withdrawn Other:_______________________________ B. Resolution Date (MM/DD/YYYY):_____________________ If not exact, provide explanation: Exact Decision Order Vacated Explanation 12. Sanction Detail: A. Were any of the following sanctions ordered? (Select all appropriate items): Bar (Permanent) Bar (Temporary/Time Limited) Censure Civil and Administrative Penalty(ies)/Fine(s) Disgorgement Expulsion Monetary Penalty other than Fines Prohibition Rescission Restitution Suspension Undertaking Cease and Desist Denial Letter of Reprimand Requalification Revocation B. Other sanctions ordered:_____________________________________________________________________________________ C. If the regulator provided in Question 1A above is the SEC, CFTC, an SRO, did the action result in a finding of a willful violation or failure to supervise? Yes No If yes, was the individual found to have: (1) 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 Municipal Securities Rulemaking Board, or to have been unable to comply with any provision of such Act, rule or regulation? Yes No (2) 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 Municipal Securities Rulemaking Board? Yes No (3) failed reasonably to supervise another person subject to the individual's supervision, with a view to preventing the violation by such 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 Municipal Securities Rulemaking Board? Yes No Page 17 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: U5 - REGULATORY ACTION DRP (CONTINUED) Rev. DRP (05/2009) D. If suspended or barred, provide: Sanction Details Sanction type: Bar (Permanent) Bar (Temporary/Time Limited) Suspension Registration Capacities affected (e.g., General Securities Principal, Financial Operations Principal, All Capacities, etc.): Duration (length of time):__________________ If not exact, provide explanation: Exact Explanation Start Date (MM/DD/YYYY):_____________________ If not exact, provide explanation: Exact Explanation End Date (MM/DD/YYYY):_____________________ If not exact, provide explanation: Exact Explanation Sanction Details Bar (Permanent) Bar (Temporary/Time Limited) Suspension Sanction type: Registration Capacities affected (e.g., General Securities Principal, Financial Operations Principal, All Capacities, etc.): Duration (length of time):__________________ If not exact, provide explanation: Exact Explanation Start Date (MM/DD/YYYY):_____________________ If not exact, provide explanation: Exact Explanation End Date (MM/DD/YYYY):_____________________ If not exact, provide explanation: Exact Explanation Sanction Details Sanction type: Bar (Permanent) Bar (Temporary/Time Limited) Suspension Registration Capacities affected (e.g., General Securities Principal, Financial Operations Principal, All Capacities, etc.): Duration (length of time):__________________ If not exact, provide explanation: Exact Explanation Start Date (MM/DD/YYYY):_____________________ If not exact, provide explanation: Exact Explanation Page 18 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: U5 - REGULATORY ACTION DRP (CONTINUED) End Date (MM/DD/YYYY):_____________________ If not exact, provide explanation: Exact Rev. DRP (05/2009) Explanation E. If requalification by exam/retraining was a condition of the sanction, provide: Requalification Details Requalification by Exam Re-Training Other Requalification type: Length of time given to requalify/retrain:__________________ Type of Exam required:___________________________________________ Yes No Has condition been satisfied? Explanation: Requalification Details Requalification type: Requalification by Exam Re-Training Other Length of time given to requalify/retrain:__________________ Type of Exam required:___________________________________________ Yes No Has condition been satisfied? Explanation: Requalification Details Requalification type: Requalification by Exam Re-Training Other Length of time given to requalify/retrain:__________________ Type of Exam required:___________________________________________ Has condition been satisfied? Yes No Explanation: F. If disposition resulted in a fine, penalty, restitution, disgorgement or monetary compensation, provide: Monetary Sanction Details Monetary Related Sanction Type: Civil and Administrative Penalty(ies)/Fine(s) Monetary Penalty other than Fines Disgorgement Restitution Total Amount: $_________________ Portion Levied against the individual: $_________________ Payment Plan: Is Payment Plan Current? Yes No Date Paid by the individual (MM/DD/YYYY):__________________ If not exact, provide explanation: Was any portion of penalty waived? If yes, amount: $_________________ Yes Exact Explanation No Page 19 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: U5 - REGULATORY ACTION DRP (CONTINUED) Rev. DRP (05/2009) Monetary Sanction Details Monetary Related Sanction Type: Civil and Administrative Penalty(ies)/Fine(s) Monetary Penalty other than Fines Disgorgement Restitution Total Amount: $_________________ Portion Levied against individual: $_________________ Payment Plan: Yes No Is Payment Plan Current? Date Paid by the individual (MM/DD/YYYY):__________________ If not exact, provide explanation: Was any portion of penalty waived? If yes, amount: $_________________ Yes Exact Explanation No Monetary Sanction Details Monetary Related Sanction Type: Civil and Administrative Penalty(ies)/Fine(s) Monetary Penalty other than Fines Disgorgement Restitution Total Amount: $_________________ Portion Levied against the individual: $_________________ Payment Plan: Is Payment Plan Current? Yes No Date Paid by the individual (MM/DD/YYYY):__________________ If not exact, provide explanation: Was any portion of penalty waived? If yes, amount: $_________________ Yes Exact Explanation No 13. Comment (Optional). You may use this field to provide a brief summary of the circumstances leading to the action as well as the current status or disposition and/or finding(s). Your information must fit within the space provided. Page 20 of 21 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U5 (05/2009) UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION INDIVIDUAL NAME: INDIVIDUAL CRD #: FIRM NAME: FIRM CRD #: U5 - TERMINATION DRP Rev. DRP (05/2009) This Disclosure Reporting Page is an INITIAL or AMENDED response to report details for affirmative response to Question(s) 7F on Form U5 Check the question(s) you are responding to, regardless of whether you are answering the question(s) "yes" or amending the answer(s) to "no": 7F(1) 7F(2) 7F(3) One event may result in more than one affirmative answer to the above items. Use only one DRP to report details related to the same termination. 1. Firm Name:__________________________________________________________________ 2. Termination Type: Discharged Permitted to Resign Voluntary Resignation 3. Termination Date (MM/DD/YYYY):_______________________ If not exact, provide explanation: Exact Explanation 4. Allegation(s): 5. Product Type(s): (select all that apply) No Product Annuity-Charitable Annuity-Fixed Annuity-Variable Banking Product (other than CD) CD Commodity Option Debt-Asset Backed Debt-Corporate Debt-Government Debt-Municipal Derivative Direct Investment-DPP & LP Interest Equipment Leasing Equity Listed (Common & Preferred Stock) Equity-OTC Futures Commodity Futures-Financial Index Option Insurance Investment Contract Money Market Fund Mutual Fund Oil & Gas Options Penny Stock Prime Bank Instrument Promissory Note Real Estate Security Security Futures Unit Investment Trust Viatical Settlement Other:________________________ 6. Comment (Optional). You may use this field to provide a brief summary of the circumstances leading to the termination. Your information must fit within the space provided. Page 21 of 21 American LegalNet, Inc. www.FormsWorkflow.com