Form Bd Uniform Application For Broker-Dealer Registration Page 23
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28CIVIL JUDICIAL ACTION DISCLOSURE REPORTING PAGE (BD)
(continuation)
2.
Principal Relief Sought: (check appropriate item)
Cease and Desist
Disgorgement
Money Damages (Private/Civil Complaint)
Restraining Order
Civil Penalty(ies)/Fine(s)
Injunction
Restitution
Other _______________
Other Relief Sought:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
3.
Filing Date of Court Action (MM/DD/YYYY):
Exact
Explanation
If not exact, provide explanation: ________________________________________________________________________________________
4. Principal Product Type: (check appropriate item)
Annuity(ies) - Fixed
Derivative(s)
Investment Contract(s)
Annuity(ies) - Variable
Direct Investment(s) - DPP & LP Interest(s)
Money Market Fund(s)
CD(s)
Equity - OTC
Mutual Fund(s)
Commodity Option(s)
Equity Listed (Common & Preferred Stock)
No Product
Debt - Asset Backed
Futures - Commodity
Options
Debt - Corporate
Futures - Financial
Penny Stock(s)
Debt - Government
Index Option(s)
Unit Investment Trust(s)
Debt - Municipal
Insurance
Other ____________________________________
Other Product Types:
________________________________________________________________________________________________________________________
5.
Formal Action was brought in (include name of Federal, State or Foreign Court, Location of Court - City or County and State or Country,
Docket/Case Number):
________________________________________________________________________________________________________________________
6.
Control Affiliate Employing Firm when activity occurred which led to the civil judicial action (if applicable):
7.
Describe the allegations related to this civil action. (The information must fit within the space provided.):
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
8.
Current Status?
Pending
On Appeal
Final
9.
If on appeal, action appealed to (provide name of court): Date Appeal Filed (MM/DD/YYYY):
________________________________________________________________________________________________________________________
10. If pending, date notice/process was served (MM/DD/YYYY):
Exact
Explanation
If not exact, provide explanation: ___________________________________________________________________________________________
(continued)
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