Intrastate or Interstate Main Office Relocation Applicat

Branch and Relocation Application
Application No.:
For your convenience, the application that you are reviewing includes all questions
contained on the type of branch/relocation application that you completed. We have
provided all questions for your review to ensure that you have an opportunity to see those
questions that you answered and the questions that you did not previously see or answer.
Your attention should be focused on those questions with answers, with the other
questions provided for your information.

National Bank Identifying Information
Charter No.:
Name of Bank:
Street address:
City:
County:
State:
Zip:
Supervisory
District:
TYPE OF APPLICATION(Check appropriate boxes)
INTRASTATE or INTERSTATE MAIN OFFICE RELOCATION
(Outside current city, town, or village limits)
To a new location
To an existing branch
Filing Fee: $0.00
Application Identifying Information
Application is made for permission to:
_ Relocate the main office to the following address.
Branch
Authorization
No.:
Street Address:
City:
County:
State:
Zip:

If this is a branch relocation, indicate the present address:

Name:
Street Address:
City:
County:
State:
Zip:
Other Information: (Check the following as applicable.)
Is this a short-distance relocation as defined in 12 CFR 5.3(I)?
Note: Branch relocations that do not meet the short distance criteria of
12 CFR 5.3(I) must also comply with advance branch closing
procedures in 12 USC 1831r-1.

Yes

No

Yes

No

If yes, please indicate which criterion applies:
_ Non-MSA (relocation is within 2-mile radius)
_ MSA (relocation is within 1-mile radius)
_ Principal city in an MSA (relocation is within 1000-feet radius)
Interstate Determination
Will the proposed new or relocated branch be located in a state that
is either the bank's main office state or a state in which the bank
will operate at least one other authorized branch at the time the
proposed branch will open?
Legal Notice
Legal notice of this application is being published on: in:
Publication
Name:
Street Address:
City:
State:
Zip:
Legal notice of this application is being published on: in:
Publication
Name:
Street Address:
City:
State:
Zip:
Contact Person
Requests for additional information or other communications about this proposal
should be directed to:

Name:
Title:
Street Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Statutory and Regulatory Factors
1. Legality
A. Is the proposed main office within 30 miles of the city, town or
village of the current main office?

Yes

No

Yes

No

Yes

No

Yes

No

D. If the bank were not relocating its main office, could the bank
establish a de novo branch at the proposed new site of the main
office?
If no, please explain.

Yes

No

E. Do you certify that two-thirds of the shareholders have voted to
approve the relocation?
If no, please explain.

Yes

No

F. Are you establishing a branch at the former main office site?
If yes, you need to file a separate branch application.

Yes

No

B. If the main office relocation is across state lines:
B.1. Is the bank retaining branches across state lines?
If yes, please identify the states and explain the legal authority to
retain the branches.

B.2. Is the bank owned by a bank holding company?
C. If the main office relocation is not across state lines:
C.1. Would the relocation of the bank's main office alter the bank's
legal authority to establish or acquire branches in any manner?
If yes, please explain.

2. Bank Premises
A. Will the proposed action result in an investment in bank premises
that requires an application or notice under 12 USC 371d (see the
"Investment in Bank Premises" booklet)?
B. If prior approval is required, has it been granted?
C. If no, is an investment request included?
D. If yes, type your investment request in the textbox below.

If no, do you wish to proceed with the application?

Yes

No

Yes
Yes

No
No

Yes

No

Yes

No

Yes

No

Yes

No

3. Management Interlocks/Insider Conflicts
Will the proposed action result in or raise an issue that could
create a prohibited
interlock(12 USC 3201-3208 and 12 CFR 26) or a conflict of
interest?
If yes, explain the circumstances that result in any potential
conflict of interest or management
interlock and specify what action will be taken to prevent a
violation of the law.

4. Environment
Will the proposed action have any significant effect on the quality
of the human environment, (for example, air and/or water quality,
noise levels, energy consumption, congestion of population, solid
waste disposal, or environmental integrity of private land) within
the meaning of the National Environmental Policy Act (NEPA), 42
USC 4321-4347, et seq? (See the Council on Environmental
Quality at www.whitehouse.gov/CEQ).
If yes, discuss the effect(s) and explain how the proposal causes
the effects.

5. Historic Properties
Will the proposed action affect any district, site, building, structure
or object listed in, or eligible for listing in, the National Register of
Historic Places pursuant to the National Historic Preservation Act
(NHPA), 16 USC 470f? (See the Advisory Council on Historic
Preservation at www.achp.gov for the Act and implementing
regulations). You are reminded that if a historic property may be
affected, no site preparation, demolition, alterations, construction
or renovation may occur without OCC's authorization.
Specify how such determination was made:

Consultation with the State Historic Preservation
Officer (SHPO) and/or Tribal Historic Preservation
Officer (THPO) (when tribal lands or historic properties
of significance to a tribe are involved).
Reviewed National Register of Historic Places (See
www.cr.nps.gov/nr).
Applied National Register criteria to unlisted
properties (See 36 CFR 60.4).
Reviewed historical records.
Contact with preservation organizations.
Other (Describe):
As appropriate, provide a copy of any documentation of
consultation with the SHPO and/or THPO. Are you providing
documentation?
If yes, provide a copy.

Yes

No

A. At its most recent examination, did the bank or any affiliated
institution receive a CRA rating of
"needs to improve" or "substantial noncompliance"?
If yes, describe what actions, if any, have been taken to redress
deficiencies in the institution's CRA
record of performance since the examination.

Yes

No

B. Will the proposed transaction affect the CRA assessment area
served
by the applicant?
If yes, discuss the effect.

Yes

No

6. Community Reinvestment Act (CRA) Considerations

7. Additional Attachments

Desired Action Date
I/We desire OCC action on this application no later than .
Certification
I hereby certify that the bank's board of directors has authorized the filing of this
application, and that to the best of my knowledge, it contains no
misrepresentations or omissions of material facts. In addition, I agree to notify the
OCC if the facts described in the filing materially change prior to receiving a
decision.
I acknowledge that any misrepresentation or omission of a material fact constitutes
fraud in the inducement and may subject me to legal sanctions provided by 18 USC
1001 and 1007.
I acknowledge that approval of this application is in the discretion of the
Comptroller of the Currency. Actions or communications, whether oral, written, or
electronic, by an agency or its employees in connection with this filing, including
approval of the application if granted, do not constitute a contract, either express or
implied, or any other obligation binding upon the agency, other federal banking
agencies, the United States, any other agency or entity of the United States, or any
officer or employee of the United States. Such actions or communications will not
affect the ability of the agency to exercise its supervisory, regulatory, or
examination powers under applicable law and regulations. I further acknowledge
that the foregoing may not be waived or modified by any employee or agent of a
federal banking agency or of the United States.

I agree I do not agree
(If you do not indicate that you agree with the terms of the certification you cannot certify.)
Signature
Signature of Authorized Officer:
Typed Name:
Title:
Date:
Name of Bank:
BankNet Security verified that was a valid signer for as of .