Form Bd Uniform Application For Broker-Dealer Registration Page 28
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28JUDGMENT / LIEN DISCLOSURE REPORTING PAGE (BD)
GENERAL INSTRUCTIONS
This Disclosure Reporting Page (DRP BD) is an
AMENDED response used to report details for affirmative responses to
INITIAL OR
Item 11K of Form BD;
;
Check
item(s) being responded to:
11K
Does the applicant have any unsatisfied judgments or liens against it?
Use a separate DRP for each event or proceeding. An event or proceeding may be reported for more than one person or entity using one DRP.
File with a completed Execution Page.
It is not a requirement that documents be provided for each event or proceeding. Should they be provided, they will not be accepted as
disclosure in lieu of answering the questions on this DRP.
NAME OF APPLICANT
APPLICANT CRD NUMBER
1.
Judgment/Lien Amount:
2.
Judgment/Lien Holder:
3.
Judgment/Lien Type: (check appropriate item)
Civil
Default
Tax
4.
Date Filed (MM/DD/YYYY):
Exact
Explanation
If not exact, provide explanation: __________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
5.
Is Judgment/Lien outstanding?
Yes
No
If No, provide status date (MM/DD/YYYY):
Exact
Explanation
If not exact, provide explanation: __________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
If No, how was matter resolved? (check appropriate item)
Discharged
Released
Removed
Satisfied
6.
Court (Name of Federal, State or Foreign Court), Location of Court (City or County and State or Country) and Docket/Case Number:
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
7.
Provide a brief summary of events leading to the action and any payment schedule details including current status (if applicable). (The
information must fit within the space provided.):
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
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