"Request for Refund Form - Nrd" - California

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NRD - Request for Refund Form
Instructions and Terms
Approved refunds will be issued by cheque mailed to the Chief AFR of the firm.
Submit the completed NRD Request for Refund Form, Sections A and B, for processing to the CSA or IIROC Regulator in the jurisdiction in
which the NRD submission has been sent. Please verify that you are sending the form only to jurisdictions where that individual is registered,
and from which a refund is expected.
For multiple jurisdiction submissions, please list all the individual's applicable jurisdictions on a single form. Send the original to the
individual's lead jurisdiction, and send copies to the other applicable jurisdictions.
Please attach a copy of the Submission Fee Summary, available on NRD in the Submission History of the pertinent submission.
Pending approval, the Regulator will forward this refund application to the NRD Administrator to process any NRD fees.
SECTION A: Refund Request made bv:
Name of Chief AFR (in full):
Legal Name of Firm (name to be printed on cheque):
Firm NRD #:
Mailing Address:
City/Town:
Province/Territory:
Postal Code:
Contact Name:
Telephone No: (
)
Fax No:
E-mail address:
Signature of Chief AFR Making this Refund Request:
Date:
YOU MUST ALSO COMPLETE SECTION B ON THE FOLLOWING PAGE
Regulator For Office Use Only:
NRD Administrator - For Office Use Only:
Date Refund Form Received by Regulator: _____________ (mm/dd/yr)
Date Refund Form Received by NRD Administrator:/___ / _ (mm/dd/yr)
Certified Correct (name/signature): _____________________________
Reviewed by NRD Administrator: _______________________________
Refund Authorized (name/signature):
Business Ops. Manager Approval: ______________________________
Refund Amount: ____________________________________________
Refund dB #: __________________ Cheque #:
Docket #: _____________________ Cheque #: ___________________
Date Completed: __ / ___ / __ (mm/dd/yr)
Date Completed: __ / ___ / ____ (mm/dd/yr)
If refund rejected, provide details:
Regulator Contact (name): ____________________________________
Telephone No: ( __ ) ________________ E-mail:
Fax No: ( __) _______________________________________________
If refund rejected, provide details:
NRD Refund Request Form
NRD - Request for Refund Form
Instructions and Terms
Approved refunds will be issued by cheque mailed to the Chief AFR of the firm.
Submit the completed NRD Request for Refund Form, Sections A and B, for processing to the CSA or IIROC Regulator in the jurisdiction in
which the NRD submission has been sent. Please verify that you are sending the form only to jurisdictions where that individual is registered,
and from which a refund is expected.
For multiple jurisdiction submissions, please list all the individual's applicable jurisdictions on a single form. Send the original to the
individual's lead jurisdiction, and send copies to the other applicable jurisdictions.
Please attach a copy of the Submission Fee Summary, available on NRD in the Submission History of the pertinent submission.
Pending approval, the Regulator will forward this refund application to the NRD Administrator to process any NRD fees.
SECTION A: Refund Request made bv:
Name of Chief AFR (in full):
Legal Name of Firm (name to be printed on cheque):
Firm NRD #:
Mailing Address:
City/Town:
Province/Territory:
Postal Code:
Contact Name:
Telephone No: (
)
Fax No:
E-mail address:
Signature of Chief AFR Making this Refund Request:
Date:
YOU MUST ALSO COMPLETE SECTION B ON THE FOLLOWING PAGE
Regulator For Office Use Only:
NRD Administrator - For Office Use Only:
Date Refund Form Received by Regulator: _____________ (mm/dd/yr)
Date Refund Form Received by NRD Administrator:/___ / _ (mm/dd/yr)
Certified Correct (name/signature): _____________________________
Reviewed by NRD Administrator: _______________________________
Refund Authorized (name/signature):
Business Ops. Manager Approval: ______________________________
Refund Amount: ____________________________________________
Refund dB #: __________________ Cheque #:
Docket #: _____________________ Cheque #: ___________________
Date Completed: __ / ___ / __ (mm/dd/yr)
Date Completed: __ / ___ / ____ (mm/dd/yr)
If refund rejected, provide details:
Regulator Contact (name): ____________________________________
Telephone No: ( __ ) ________________ E-mail:
Fax No: ( __) _______________________________________________
If refund rejected, provide details:
NRD Refund Request Form
Section B: Request for Refund Schedule
NAME OF FIRM: _______________________________________________________________________
For refunds on Duplicate individuals:
Under "Individual Registrant Information / NRD#", list the NRD number of the correct individual.
Under "Additional Information", list the NRD number of the duplicate individual.
For refunds on Corrective submissions:-
Under "NRD submission #", list the submission number for which you are requesting a refund. This is the corrective submission.
Under "Additional Information", list the original incorrect submission for which the corrective submission(s) was/were made.
REFUND REQUESTED
REFUND TYPE
INDIVIDUAL REGISTRANT
SUBMISSION
SUBMISSION
ADDITIONAL
JURIS-
NUMBER*
EFT
INFORMATION
#
DATE
INFORMATION
DICTION(S)
(see below)
IDENTIFIER
Commis-
IIROC
NRD Fee
NRD #
NAME
DD/MM/YYYY
sion
*Refund Type
1
Missing Individual (no tombstone data)
2
Duplicate Individual
3
Individual has already been terminated
4
Abandoned submission
5
Personal information change notice fee incorrectly charged
6
Proficiency information change notice fee incorrectly charged
7
Employment location change notice fee incorrectly charged
8
Annual fee incorrectly charged
9
Open a location fee incorrectly charged
10
Other (please specify)
NRD. Refund Request Form
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