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Midwest ISO's real-time market design with energy and ancillary service co-optimization is reported in this paper. The key components of Midwest ISO's real-time market are described including intra-day reliability commitment, transmission security management, real-time dispatch and pricing. The RT SCED formulation at the core of the real-time dispatch and pricing market is presented. Numerical examples are included to illustrate the primary features of the real-time market.