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INSTRUCTIONS

Rev. Form U5 (10/2005)

UNIFORM TERMINATION NOTICE FOR SECURITIES INDUSTRY REGISTRATION

firm(s) from which the individual seeks to terminate

All signatures required on the Form U5 filing must be made in

registrations and indicate the registrations the individual seeks

this section. A “signature” includes a manual signature or an

to terminate. For full terminations, select the affiliated firm(s)

electronically transmitted equivalent.

from which the individual seeks to terminate.

Date.

Enter the date that the form was signed by the

•

File separate Sections 5A and 5B for each affiliated

Appropriate

Signatory.

The

entry

must

numeric

firm if the SRO and/or jurisdiction terminations

(MM/DD/YYYY). Future dates may not be entered in this

requested with the firms named in this section differ

section.

from the terminations requested with the filing firm.

Signature of Appropriate Signatory. NOTE: A signatory

entry is required for all filings. For purposes of an electronic

Affiliated Firm CRD Number. Enter the affiliated firm’s CRD

form filing, a signature is effected by typing a name in the

Number here.

designated signature field. Enter the full legal signature as it

appears in typed or printed form. By typing a name in this field,

Affiliated Firm Name. Enter the affiliated firm’s name here.

the signatory acknowledges and represents that the entry

This should be the name of the affiliated firm as listed on the

constitutes in every way, use, or aspect, his or her legally

Form BD or Form ADV. Do not abbreviate, shorten or

binding signature.

otherwise modify the firm name in any way.

For paper filers, enter the full legal signature as it appears in

Affiliated Firm Designation - Broker-Dealer or Investment

typed or printed form. The signatory’s full legal name must also

Adviser (BD/IA). Select the appropriate radio button (paper

be displayed under the signature. The name must be typed or

filers check the appropriate box) marked as “BD” or “IA” to

printed as it appears in the signature form.

indicate whether the affiliated firm is a broker-dealer or an

investment adviser.

Person to Contact for Further Information. Enter the name

of the person to contact for additional information regarding the

Affiliated Firm Billing Code. Enter the billing code of the

matters reported on this form. Include the telephone number for

affiliated firm. A billing code is an alpha/numeric value

the person listed.

consisting of up to eight characters established by the firm. If

the firm does not use billing codes, leave this field blank.

8A. FIRM ACKNOWLEDGMENT

Office of Employment Address Street 1/Street 2. The office

This section must be completed on all U5 form filings

of employment address will prepopulate based on the

submitted by the firm.

information provided on the Form U4.

8B. INDIVIDUAL ACKNOWLEDGMENT AND CONSENT

7. DISCLOSURE QUESTIONS

This section must be completed on amendment U5 form

Disclosures

filings where the individual is submitting changes to Part II

This section applies to full terminations only.

of the INTERNAL REVIEW DRP or changes to Section 2

(CURRENT RESIDENTIAL ADDRESS).

To complete this section, check “yes” or “no” for each question.

Refer to the Explanation of Terms if necessary. For any “yes”

APPENDIX

answer, provide a detailed explanation on the appropriate

Disclosure Reporting Page (DRP U5). The Disclosure

Drop-Down Pick Lists

Questions are as follows:

Investigation Disclosure

Internal Review Disclosure

Select as appropriate from the following pick lists the answers

Criminal Disclosure

to the questions that contain drop-down choices. The choices

Regulatory Action Disclosure

below match the pick lists that appear on the electronic

Customer Complaint/Arbitration/Civil

screens

Litigation Disclosure

Termination Disclosure

Termination

Reason for Termination: *Discharged, *Other, *Permitted to

About Internal Review.

Generally, the Internal Review

Resign, Deceased, Voluntary.

Disclosure question in Question 7B and the Internal Review

Reporting Page (DRP U5) are used to report matters relating to

General

compliance, not matters of a competitive nature. Responses

State:

Alabama,

Alaska,

Arizona,

Arkansas,

California,

should not include situations relating to disputes between the

Colorado, Connecticut, Delaware, District of Columbia, Florida,

firm and the individual over ownership or possession of

Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas,

information or records pertaining to business conducted by the

Kentucky,

Louisiana,

Maine,

Maryland,

Massachusetts,

individual. If a “yes” answer is provided to the Internal Review

Michigan,

Minnesota,

Mississippi,

Missouri,

Montana,

Disclosure question, the individual whose name appears in

Nebraska, Nevada, New Hampshire, New Jersey, New Mexico,

Section 1 (GENERAL INFORMATION) of this form may provide

New York, North Carolina, North Dakota, Ohio, Oklahoma,

a brief summary of the event on Part II of the Internal Review

Oregon, Pennsylvania, Puerto Rico, Rhode Island, South

Disclosure Reporting Page (DRP U5).

Carolina, South Dakota, Tennessee, Texas, Utah, Vermont,

Virginia, Washington, West Virginia, Wisconsin, Wyoming

8. SIGNATURE

Page 4 of 6

Instructions For Form U5 - Uniform Termination Notice For Securities Industry Registration Page 4

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