Form you mean, yes, that's what it is asking for.
§ 240.12g-4 Certifications of termination of registration under section 12(g).
(a) Termination of registration of a class of securities under section 12(g) of the Act ( 15 U.S.C. 78l(g)) shall take effect 90 days, or such shorter period as the Commission may determine, after the issuer certifies to the Commission on Form 15 ( § 249.323 of this chapter) that the class of securities is held of record by:
(1) Fewer than 300 persons, or in the case of a bank; a savings and loan holding company, as such term is defined in section 10 of the Home Owners' Loan Act ( 12 U.S.C. 1461); or a bank holding company, as such term is defined in section 2 of the Bank Holding Company Act of 1956 ( 12 U.S.C. 1841), 1,200 persons; or
