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Financial (Federal Deposit Insurance Corporation)

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U.S.A. forms for Federal Deposit Insurance Corporation

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DEPOSIT BROKER SUBMISSION CHECKLIST
BROKER NAME:
DTC BROKER NUMBER:
MAILING ADDRESS:
CONTACT PERSON:
Telephone Number:
Fax Number:
Email address:
SECONDARY PERSON:
Telephone Number:
Fax Number:
Email address:
DATA PROCESSING CONTACT:
Telephone Number:
Fax Number:
Email address:
SECONDARY PERSON:
Telephone Number:
Fax Number:
Email address:
DATA SUBMISSION:
We are submitting a file in the required format:
Yes
Please note that only data submitted in the prescribed format will be processed. Manual listings will not
be accepted. Please label your diskette(s) or compact disc(s) with your firm’s name and DTC broker
number, if applicable.
Number of Records on the file:
Principal Value:
NOTE: The principal value listed above should be the same as the data on the file. If the above stated
data does not balance, the file will not be processed and your firm will lose its position in the processing
sequence.
The undersigned affirms that all of the information submitted is correct and contains no material omissions and that to
the best of his/her knowledge, the data submitted is a final, complete and accurate submission including
information from ALL sub-brokers/agents, if any, with the exception of brokers (indicate number) in the
amount of $ (total) which are included in the aggregate on the file. I understand that my firm will not be paid
these sums until the sub-tier broker submits complete investor information and required documentation to the FDIC.
Prepared by:
Date:
FOR FDIC USE ONLY
BALANCE VERIFIED
DATA LOADED
DATA UNLOADED
DATA LOADED
LOAD CERTIFIED
DATA GROUPED
INFORMATION FAXED
Financial Institution:
Deposit Account Number:
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Financial (Federal Deposit Insurance Corporation)

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Completed 18 July 2020

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