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Form U6 (For CRD Individual)

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Form U6 (For CRD Individual) Form. This is a Official Federal Forms form and can be use in FINRA.

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Rev. Form U6 (05/2009) INDIVIDUAL NAME: INDIVIDUAL CRD #: U6 - SUBJECT OF ACTION FIRST NAME: MIDDLE NAME: SUFFIX: ALIAS: DOB (MM/DD/YYYY): LAST NAME: SSN: CRD #: RESIDENTIAL STREET ADDRESS LINE 1: RESIDENTIAL STREET ADDRESS LINE 2: CITY: COUNTRY: STATE: ZIP/POSTAL CODE: RESIDENTIAL STREET ADDRESS LINE 1: RESIDENTIAL STREET ADDRESS LINE 2: CITY: COUNTRY: STATE: ZIP/POSTAL CODE: BUSINESS STREET ADDRESS LINE 1: BUSINESS STREET ADDRESS LINE 2: CITY: COUNTRY: REGULATOR CONTACT: STATE: ZIP/POSTAL CODE: REGULATOR PHONE NUMBER: Page 1 of 15 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U6 (05/2009) INDIVIDUAL NAME: INDIVIDUAL CRD #: DISCLOSURE REPORTING PAGES U6 - BANKRUPTCY/SIPC/COMPROMISE WITH CREDITORS DRP Rev. DRP (05/2009) This Disclosure Reporting Page is an INITIAL or AMENDED 1. Action Type (select appropriate item): Bankruptcy [Circle one: Chapter 7, Chapter 11, Chapter 13, Other] Compromise Declaration Liquidation Receivership 2. Action Date (MM/DD/YYYY) (Provide date bankruptcy was filed, or date SIPC was initiated, or date of compromise with creditor):_____________________________ If not exact, provide explanation: Other:_________________________ Exact Explanation 3. If the financial action relates to an organization over which the subject exercise(d) control, provide: A. Organization Name:____________________________________________________________________ B. Position, title or relationship:____________________________________________________________________ C. Investment-related business? Yes No State Court Foreign Court Other:___________________________ 4. Court action brought in: Federal Court A. Name of Court (Federal, State, Foreign or Other):____________________________________________________________________ B. Location of Court (City or County and State or Country):_______________________________________________________________ C. Docket/Case#:______________ Check this box if the Docket/Case# is the subject's SSN, a Bank Card number, or a Personal Identification Number. 5. Is action currently pending? Yes No 6. If not pending, provide Disposition Type (select appropriate item): Direct Payment Procedure Discharged Dismissed Dissolved Satisfied/Released Other:__________________________ 7. Disposition Date (MM/DD/YYYY):________________________________ If not exact, provide explanation: Exact SIPA Trustee Appointed Explanation 8. If a compromise with creditors, provide: A. Name of Creditor:____________________________________________________________________ B. Original amount owed: $____________ C. Terms/Compromise reached with creditor: 9. If a SIPA trustee was appointed or a direct payment procedure was begun: A. Provide the amount paid or agreed to be paid by the subject: $____________ ; or The name of the Trustee:____________________________________________________________________ Yes No B. Currently Open? C. Date Direct Payment Initiated/Filed or Trustee Appointed (MM/DD/YYYY):_________________________ Exact Explanation If not exact, provide explanation: 10. 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. Include the details as to creditors, terms, conditions, amounts due and settlement schedule (if applicable). Your information must fit within the space provided. Page 2 of 15 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U6 (05/2009) INDIVIDUAL NAME: INDIVIDUAL CRD #: Rev. DRP (05/2009) U6 - CIVIL JUDICIAL DRP This Disclosure Reporting Page is an INITIAL or AMENDED 1. Court Action intiated by: A. Select appropriate item: SEC Other Federal Agency Jurisdiction Foreign Financial Regulatory Authority Firm Private Plaintiff B. Name of party initiating the proceeding:___________________________________________ 2. Relief Sought: (select all that apply): Cease and Desist Civil and Administrative Penalty(ies)/Fine(s) Disgorgement Injunction Monetary Penalty other than Fines Restitution 3. A. Filing Date of Court Action (MM/DD/YYYY):_________________ If not exact, provide explanation: B. Date notice/process was served (MM/DD/YYYY):_________________ If not exact, provide explanation: 4. Product Type(s): (select all that apply) No Product Annuity-Charitable Annuity-Fixed Annuity-Variable Banking Products (other than CDs) CD Commodity Option Debt-Asset Backed Debt-Corporate Debt-Government Debt-Municipal Restraining Order Other: Exact Explanation Exact Explanation Derivative Direct Investment-DPP & LP Interests 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:________________________ 5. Formal Action was brought in: 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#:______________ 6. Employing Firm when activity occurred which led to the civil judicial action:________________________________________________ 7. Describe the allegations related to this civil action. (Your information must fit within the space provided.): 8. Current Status? Pending On Appeal Final 9. If pending and any limitations or restrictions are currently in effect, provide details: Page 3 of 15 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U6 (05/2009) INDIVIDUAL NAME: INDIVIDUAL CRD #: Rev. DRP (05/2009) U6 - CIVIL JUDICIAL DRP (CONTINUED) 10. If on appeal: A. Action appealed to (provide name of court):____________________________________________________ B. Court Location:_______________________________________________________________ C. Docket/Case#:______________ D. Date appeal filed (MM/DD/YYYY):_____________________ Exact Explanation If not exact, provide explanation: E. Appeal details (including status): F. If on Appeal and any limitations or restrictions are currently in effect, provide details. 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): Consent Judgment Rendered Vacated Vacated Nunc Pro Tunc / ab initio Withdrawn Settled Dismissed Other:______________________ B. Resolution Date (MM/DD/YYYY):_____________________ Exact Explanation If not exact, provide explanation: 12. Sanction Detail: A. Were any of the following Sanctions Ordered or Relief Granted? (select all that apply): Civil and Administrative Penalty(ies)/Fine(s) Injunction Cease and Desist Monetary Penalty other than fines Disgorgement Restitution B. Other Sanctions:___________________________________________________________________________________ C. If enjoined, provide: Injunction Details 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 Page 4 of 15 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U6 (05/2009) INDIVIDUAL NAME: INDIVIDUAL CRD #: U6 - CIVIL JUDICIAL DRP (CONTINUED) Rev. DRP (05/2009) Injunction Details 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 Injunction Details 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 D. If disposition resulted in a fine, penalty, restitution, disgorgement or monetary compensation, provide: Monetary Related Sanction Details Monetary Related Sanction Type: Monetary Fine Explanation: Disgorgement Total Amount: $_________________ Portion levied against the subject: $_________________ Date Paid by the subject (MM/DD/YYYY):_____________________ If not exact, provide explanation: Was any portion of penalty waived? If yes, amount: $_________________ Yes Restitution Exact Other (requires explanation) Explanation No Page 5 of 15 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U6 (05/2009) INDIVIDUAL NAME: INDIVIDUAL CRD #: Rev. DRP (05/2009) U6 - CIVIL JUDICIAL DRP (CONTINUED) Monetary Related Sanction Details Monetary Related Sanction Type: Monetary Fine Explanation: Disgorgement Total Amount: $_________________ Portion levied against the subject: $_________________ Date Paid by the subject (MM/DD/YYYY):_____________________ If not exact, provide explanation: Was any portion of penalty waived? If yes, amount: $_________________ Yes Restitution Exact Other (requires explanation) Explanation No Monetary Related Sanction Details Monetary Related Sanction Type: Monetary Fine Explanation: Disgorgement Total Amount: $_________________ Portion levied against the subject: $_________________ Date Paid by the subject (MM/DD/YYYY):_____________________ If not exact, provide explanation: Was any portion of penalty waived? If yes, amount: $_________________ Yes Restitution Exact Other (requires explanation) 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 final disposition and/or finding(s). Include the number of investors in the reporting jurisdiction, the total number of investors in the program, the amount invested in the reporting jurisdiction, and the total amount invested. Your information must fit within the space provided. Page 6 of 15 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U6 (05/2009) INDIVIDUAL NAME: INDIVIDUAL CRD #: U6 - CRIMINAL DRP Rev. DRP (05/2009) This Disclosure Reporting Page is an INITIAL or AMENDED 1. If charge(s) were brought against an organization over which the subject exercise(d) control: A. Organization Name:____________________________________________________________________ B. Investment-related business? Yes No C. Position, title or relationship:____________________________________________________________________ 2. Formal action was brought in: Federal Court State Court Military Court Foreign Court Other:________________________ A. Name of Court (Federal, State, Military, Foreign or Other):____________________________________________________________ B. Location of Court (City or County and State or Country):______________________________________________________________ C. Docket/Case#:______________ 3. 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 4. 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 7 of 15 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U6 (05/2009) INDIVIDUAL NAME: INDIVIDUAL CRD #: Rev. DRP (05/2009) U6 - 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):________ Misdemeanor Specify if amended or reduced charge is a Felony or Misdemeanor: Felony 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 8 of 15 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U6 (05/2009) INDIVIDUAL NAME: INDIVIDUAL CRD #: Rev. DRP (05/2009) U6 - 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: 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)___________________________ Exact Explanation Exact Explanation If not exact, provide explanation: 5. 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. Include the relevant dates when the conduct that was the subject of the charge(s) occurred. Include the number of investors in the reporting jurisdiction, the total number of investors in the program, the amount invested in the reporting jurisdiction, the total amount invested and whether the action is based on a referral or investigation from your securities division. Your information must fit within the space provided. Page 9 of 15 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U6 (05/2009) INDIVIDUAL NAME: INDIVIDUAL CRD #: U6 - REGULATORY ACTION DRP Rev. DRP (05/2009) This Disclosure Reporting Page is an INITIAL or AMENDED 1. Regulatory Action initiated by: A. (Select appropriate item): SEC Other Federal Agency Federal Banking Agency Jurisdiction SRO CFTC Foreign Financial Regulatory Authority National Credit Union Administration 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 Products (other than CDs) CD Commodity Option Debt-Asset Backed Debt-Corporate Debt-Government Debt-Municipal Derivative Direct Investment-DPP & LP Interests 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 10 of 15 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U6 (05/2009) INDIVIDUAL NAME: INDIVIDUAL CRD #: Rev. DRP (05/2009) U6 - 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 14 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. Does the order constitute a final order based on violations of any laws or regulations that prohibit fraudulent, manipulative, or Yes No deceptive conduct? 13. 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 subject 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 Yes No regulation? (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 Yes No Rulemaking Board? (3) failed reasonably to supervise another person subject to the subject'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 Yes No rules of the Municipal Securities Rulemaking Board? Page 11 of 15 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U6 (05/2009) INDIVIDUAL NAME: INDIVIDUAL 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 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 (Temporary/Time Limited) Suspension Sanction type: Bar (Permanent) 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 12 of 15 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U6 (05/2009) INDIVIDUAL NAME: INDIVIDUAL CRD #: U5 - REGULATORY ACTION DRP (CONTINUED) Exact End Date (MM/DD/YYYY):_____________________ If not exact, provide explanation: Rev. DRP (05/2009) Explanation E. If requalification by exam/retraining was a condition of the sanction, provide: Requalification Details Re-Training Other Requalification type: Requalification by Exam 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: 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 subject: $_________________ Payment Plan: Is Payment Plan Current? Yes No Date Paid by the subject (MM/DD/YYYY):__________________ If not exact, provide explanation: Was any portion of penalty waived? If yes, amount: $_________________ Yes Exact Explanation No Page 13 of 15 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U6 (05/2009) INDIVIDUAL NAME: INDIVIDUAL 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 subject: $_________________ Payment Plan: Yes No Is Payment Plan Current? Date Paid by the subject (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 subject: $_________________ Payment Plan: Is Payment Plan Current? Yes No Date Paid by the subject (MM/DD/YYYY):__________________ If not exact, provide explanation: Was any portion of penalty waived? If yes, amount: $_________________ Yes Exact Explanation No 14. 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 and/or finding(s). Include relevant terms, conditions and dates. Include the number of investors in the reporting jurisdiction, the total number of investors in the program, the amount invested in the reporting jurisdiction, the total amount invested and whether the action is based on a referral or investigation from your securities division. Your information must fit within the space provided. Page 14 of 15 American LegalNet, Inc. www.FormsWorkflow.com Rev. Form U6 (05/2009) INDIVIDUAL NAME: INDIVIDUAL CRD #: Rev. DRP (05/2009) U6 - SRO ARBITRATION DRP This Disclosure Reporting Page is an INITIAL or AMENDED 1. Case Name: ________________________________________________________ 2. Arbitration/Reparation filed with: _________________________________________________________ 3. Date case was initiated (MM/DD/YYYY): ____________________ 4. Docket/Case#: __________________ 5. Employing Firm when events occurred which led to the arbitration/reparation: 6. Allegation(s): 7. 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:________________________ 8. Alleged Compensatory Damage Amount: $___________________________ 9. Is arbitration/reparation currently pending? Yes No 10. Resolution Details: A. If status is not pending, how was arbitration/reparation resolved? Award Denied Dismissed Other Settled Stipulated Award Withdrawn B. Resolution Date (MM/DD/YYYY): ____________________ C. Disposition Details: 11. Comment (Optional). You may use this field to provide a brief summary of the circumstances leading to the action as the current status or disposition. Your information must fit within the space provided. Page 15 of 15 American LegalNet, Inc. www.FormsWorkflow.com