Interagency Biographical and Financial Report

OMB No. for FDIC 3064-0006 Expires November 30, 2007
OMB No. for OCC 1557-0014 Expires November 30, 2007
OMB Nos. for OTS 1550-0005, -0015, -0047 Expires November 30, 2007
OMB No. for FRB 7100-0134 Expires October 31, 2007

INTERAGENCY BIOGRAPHICAL AND FINANCIAL REPORT
Public reporting burden for this collection of information is estimated to average two hours for biographical
information and two hours for financial information. This estimate includes time to gather and maintain data in the
required form, to review instructions, and to complete the information collection. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden
to: Paperwork Reduction Act, Legal Division, Federal Deposit Insurance Corporation, 550 17th Street, NW,
Washington, DC 20429; Secretary, Board of Governors of the Federal Reserve System, 20th and C Streets, NW,
Washington, DC 20551; Licensing Activities Division, Comptroller of the Currency, 250 E Street, SW,
Washington, DC 20219; or Office of Supervision Policy, Office of Thrift Supervision, 1700 G Street, NW,
Washington, DC 20552; and to the Office of Management and Budget, Paperwork Reduction Project, Washington,
DC 20503.
An organization or a person is not required to respond to a collection of information unless it displays a currently
valid OMB control number.

General Information and Instructions
This Interagency Biographical and Financial Report (report) is used by individuals1 in
conjunction with other corporate filings to the appropriate regulatory agency. This report is
not a stand-alone document.
Preparation
Use of this report format is not mandatory. If an alternative format is used, it must provide all
requested information, including the certification. All questions must be answered with
complete and accurate information that is subject to verification. If the answer is “none,” “not
applicable,” or “unknown,” so state. Answers of “unknown” or “yes” should be explained.
The questions are not intended to limit the presentation nor are the questions intended to
duplicate information supplied on another form or in an exhibit. For example, a crossreference to the information is acceptable. Any cross-reference must be made to a specific cite
or location in the documents, so the information can be located easily. Use additional sheets as
necessary. Each regulatory agency will provide additional instructions for use and preparation.
If the report is not complete, the regulatory agency may either request additional information
or return the filing. If you are a foreign national or a United States citizen who currently
resides in a foreign country, additional information may be necessary.
1

A company seeking to acquire direct or indirect control of a bank or thrift should consult with the appropriate
regulatory agency for filing instructions.
i

Financial statements from individuals must have “as of” dates of not more than 90 days prior
to the date the financial report is submitted. All amounts in this report must be based on
current market value in United States dollars2 and agree with any totals in the supplementary
schedules. In addition to the sample financial schedules, you may wish to provide
supplementary schedules for other items on the financial statement. If the sample financial
statement is used, an answer is required to each item. If you submit an alternative Financial
Report format, the information must respond to each request for information contained in the
sample Financial Report.
In addition, each regulatory agency specifically reserves the right to require up to five years of
financial data from any acquiring person as well as the filing of additional information or
statements, such as a federal income tax return or a current appraisal to support an asset's
value.
If you have been convicted of any criminal offense involving dishonesty, breach of trust, or
money laundering, or have agreed to enter into a pretrial diversion or similar program in
connection with a prosecution of such offense (12 U.S.C. § 1829), you must obtain approval
from the FDIC before you can own, control, participate in the affairs of, or become an
institution-affiliated party of a depository institution.
Each individual must report promptly any material change in the biographical report or
financial condition that occurs during the review period for the filing. For additional
information regarding the processing procedures and guidelines and any supplemental
information that may be required, refer to the appropriate regulatory agency's procedural
guidelines (that is, the Comptroller's Licensing Manual, the FDIC's Rules and Regulations (12
C.F.R. Part 303), or the OTS' Application Processing Handbook), contact the agency directly
for specific instruction, or visit its Web site at www.occ.treas.gov, www.fdic.gov,
www.ots.treas.gov, or www.federalreserve.gov.
Definitions
For purposes of this document:
Affiliate means any company that owns or controls, is owned or controlled by, or is under
common ownership or control with a depository institution or depository institution holding
company.
Associated means associated as an officer, director, organizer, partner, trustee, or principal
shareholder or owner.
2

Provide the foreign currency exchange rate and conversion date, if applicable.

ii

Company means any corporation, association, partnership, limited liability company, business
trust, sole proprietorship, joint venture, or other similar organization.
Depository institution means any bank (including a national, state, district, or foreign bank),
savings association, savings bank, savings and loan association, building and loan association,
homestead association, cooperative bank, trust company, industrial bank or loan company, or
credit union. A United States office, including a branch or agency, of a foreign bank is a
depository institution.
Management official includes a senior executive officer; director; advisory or honorary director of
a depository institution with total assets of $100 million or more; branch manager; trustee of a
depository organization under the control of trustees; and any person who has a representative or
nominee serving in any of those capacities.
Principal shareholder or owner means a person who directly or indirectly owns, controls, or
holds (either individually or as a member of a group) the power to vote 10 percent or more of
any class of voting securities or other voting equity interest of the entity.
Confidentiality
Any individual desiring confidential treatment of specific portions of the report must submit a
request in writing with the report. The request must discuss the justification for the requested
treatment. The individual's reasons for requesting confidentiality should specifically
demonstrate the harm (for example, loss of competitive position, invasion of privacy) that
would result from public release of information (5 U.S.C. section 552). Information for which
confidential treatment is requested should be: (1) specifically identified in the public portion of
the report (by reference to the confidential section); (2) separately bound; and (3) labeled
“Confidential.” The individual should follow the same procedure for a request for confidential
treatment for the subsequent filing of supplemental information to the report.
The individual should contact the appropriate regulatory agency for specific instructions
regarding requests for confidential treatment. The agency will determine whether the
information will be treated as confidential and will advise the individual of any decision to
make available to the public information labeled “Confidential.”

iii

INTERAGENCY BIOGRAPHICAL AND FINANCIAL REPORT
This is filed with respect to:
_________________________________________________________________________________
Name of Subject Institution or Holding Company, Location
Type of Filing
†
†
†
†
†
†
†
†
†

Position

Bank or Thrift Charter
Bank or Thrift Holding Company
Change in Bank Control
Change in Senior Executive Officer or Director
Citizenship Waiver
Charter Conversion
Deposit Insurance
Federal Branch or Agency
Other ________________________

† Organizer
† Director
† Senior Executive Officer
Title: ______________________
† Principal Shareholder
† Trustee
† Manager
† Other _______________________

BIOGRAPHICAL REPORT
1. Personal Information
(a) Name

________________________________________________________________
(Last)
(First)
(Middle—no initials)

(b) Residence _________________________________________________________________
(Street Address)
_________________________________________________________________
(City)
(State)
(ZIP Code)
(Country)
(c) If at residence less than five years, list addresses and dates occupied for past five years.
Date From

Date To

Number and Street

(d) Date of birth: Month _________

Day _____

City

State

ZIP Code

Year _________

(e) Place of birth: ______________________________________________________
(City)
(State)
(Country)

1

Country

(f) United States Social Security Number: ___________________________________
(g) Citizenship _________________________________________________________
(Country)
(Date, if Naturalized)
(h) If not a United States citizen, provide:
Passport Number ____________________________________________
Home Country Identification Number ____________________________
Immigration File Number ____________________________________
Father's full name ___________________________________________________
Mother's full name, including maiden name ______________________________
(i)

Telephone and fax numbers where you may be reached during business hours and an e-mail
address:
___________________________________________________________________________
(Area Code, Telephone Number, including Country Code if outside U.S.)
___________________________________________________________________________
(Fax Number)
E-mail Address

(j) List other names you used and the period of time you used them (for example, your maiden
name, name by a former marriage, former name, alias, or nickname). If the other name is
your maiden name, put “nee” in front of it.

2. Employment Record
(a) List employment in reverse chronological order for the last five years. The list should
include the beginning and ending dates of employment, the employer’s name and
location (city, state), nature of business, title or position, nature of duties, and reason
for leaving.

(b) Have you ever been dismissed or asked to resign from any past employment, including
a less than honorable discharge from military service?
† Yes
† No
If “yes,” provide the employer’s name, address, and telephone number; title or
position; date of discharge; and explanation.

2

3. Education and Professional Credentials
(a) List each diploma or degree from high schools, colleges, universities, or other schools.
School's Name/Location

From

To

Degree

(b) List each professional license or similar certificate you now hold or have held (for
example, Attorney, Physician, CPA, NASD or SEC registration).
License

Issuing Authority

Date Issued

Status

Expiration

4. Business and Banking Affiliations
(a) List any company with which you are associated, providing the company name,
location, nature or type of business, position held or relationship to the company,
ownership percentage, and beginning date of the relationship.

(b) List the name of any depository institution or depository institution holding company
with which you are or were associated. Also list the location, nature of banking
activity, position held or relationship, ownership percentage, and beginning and ending
dates of the relationship.

3

(c) Are you in the process of being considered for a senior executive officer or director
position at another depository institution or depository institution holding company?
† Yes
† No
If “yes,” provide the name of the depository institution or depository institution holding
company and the position. If the application has been submitted for regulatory review,
provide the name of the regulatory agency.

(d) Are you now or are you proposed to be a “management official” of another insured
depository institution or depository institution holding company? † Yes
† No
If “yes,” explain either why the potential interlock is not a violation of the Depository
Institution Management Interlocks Act (12 U.S.C. §§ 3201-3208) or what action will be
taken to prevent a violation.

5. Legal and Related Matters
(a)

Have you been involved in any of the following filings where the filing was denied,
disapproved, withdrawn, or otherwise returned without favorable action by a federal or
state regulatory authority or a self-regulatory organization:
(1)

A charter or license application, a depository institution holding company
application, or a federal deposit insurance application, in which you were listed
as an organizer, director, senior executive officer, or a person that would own
or control (either individually or as a member of a group) 10 percent or more of
any class of voting securities or other voting equity interest of the institution, or
similar position?
† Yes
† No

(2)

A merger application in which you were listed as a director, senior executive
officer, or similar position?
† Yes
† No

(3)

A notice of change in director or senior executive officer, or similar form, in
which you were listed as a director, senior executive officer, or similar position?
† Yes
† No

4

(4)

A notice of change in control for a depository institution or other company, or a
similar form, in which you were listed (either individually or as a member of a
group) as an acquirer or transferee?
† Yes
† No

(5)

Any other application, notice, or other regulatory or administrative request
which was filed with a federal or state regulatory authority or a self-regulatory
organization in which you were listed in some capacity?
† Yes
† No

(b)

Have you or any depository institution or depository institution holding company with
which you are or were associated been subject to any supervisory agreement,
enforcement action, civil money penalty, prohibition or removal order, or other
supervisory or administrative action taken or imposed by any federal or state regulatory
authority or other governmental entity?
† Yes
† No

(c)

Has any depository institution with which you are or were associated:
(1)

(d)

Been placed into conservatorship or receivership or otherwise failed?
† Yes

† No

(2)

Received financial assistance from a federal agency or instrumentality (for
example, FDIC, Resolution Trust Corporation, Federal Savings and Loan
Insurance Corporation)?
† Yes
† No

(3)

Merged with or been acquired by an institution that received financial assistance
from a federal agency or instrumentality in connection with the transaction?
† Yes
† No

Have you or any company with which you are or were associated:
(1)

Filed a petition under any chapter of the Bankruptcy Code or had an involuntary
bankruptcy petition filed against you or the company?
† Yes
† No

(2)

Defaulted on a loan or financial obligation of any sort, whether as obligor,
cosigner, or guarantor?
† Yes
† No

(2)

Forfeited property in full or partial satisfaction of any financial obligation?
† Yes
† No

(3)

Had a lien placed against property for failure to pay taxes or other debts?
† Yes
† No

(4)

Had wages or income garnished for any reason?

† Yes

† No

(5)

Failed or refused to pay any outstanding judgments?

† Yes

† No

5

(e)

Have you or any company or depository institution with which you are or were
associated been involved in any lawsuit, formal or informal investigation, examination,
or administrative proceeding that may result in, or resulted in, any penalty (including,
but not limited to, any sanction, fine, order to pay damages, loss of right or benefit,
forfeiture of property interest, or revocation of license), agreement, undertaking,
consent, judgment, or order imposed by or entered into with any of the following
entities:
(1)

Any federal or state court?

† Yes

(2)

Any department, agency, or commission of the United States government?
† Yes
† No

(3)

Any state, municipal, or foreign governmental entity?
† Yes

(4)

† No

† No

Any self-regulatory organization (for example, NASD, FASB, state bar)?
† Yes
† No

(f)

Have you or any company or depository institution with which you are or were
associated been arrested for, charged with, indicted for, or convicted of (including a
conviction where the record was expunged), or ever pleaded nolo contendere to, any
criminal matter (other than minor traffic violations)?
† Yes
† No

(g)

If you answer “yes” to any question in 5(a) through 5(f), provide your explanation by
identifying the number of the question, describing the situation in detail, and, where
relevant, including the:
•
•
•
•
•

•
•
•
•

Name and location of any institution, company, party, court, regulatory agency, or
self-regulatory organization involved.
Nature of your association with any institution or company (for example, officer,
director, organizer, principal shareholder, or owner).
Type of any application, notice, or other regulatory or administrative request.
Nature of any supervisory, enforcement, or administrative action.
Direct and indirect debt terms, defaulted amount, and creditor regarding any
financial obligation.
Date of any relevant event.
Nature of any lawsuit, charge, or proceeding.
Jurisdiction in which any legal proceeding occurred.
Resolution or disposition of the matter.

6

6. Additional Information
Present any other information you believe is important to evaluate your filing. If you are
involved in the organization of a new depository institution or depository institution holding
company, discuss your specific role.

7

FINANCIAL REPORT
FINANCIAL STATEMENT AS OF _______________________, ______

ASSETS

LIABILITIES AND NET
WORTH

Cash on hand and in
depository institutions

$___________

Accounts payable

$___________

____________

Notes payable and other
loans (Schedule F)

____________

Marketable securities
(Schedule A)

____________

____________

Real estate mortgages
(Schedule C)
Other liabilities (Schedule G)

____________

TOTAL LIABILITIES

____________

Net worth (Total assets less
total liabilities)

____________

TOTAL LIABILITIES AND
NET WORTH

$

Notes receivable
(Schedule B)
Real estate
(Schedule C)

____________

Proprietary interests and
other securities
(Schedule D)

____________

Retirement funds and other
assets (Schedule E)

____________

TOTAL ASSETS

$

8

CONTINGENT LIABILITIES
In addition to the liabilities listed on the Financial Statement, have you endorsed, guaranteed, or become
otherwise indirectly or contingently liable for the debts of others or through a pending lawsuit?
† Yes

† No

If “yes,” complete the following:

Name and Address of
Debtor or Obligor

Name and Address of
Creditor or Obligee

Description and Value of Collateral

TOTAL

Date
Due

Current
Amount

$

9

SUPPORTING SCHEDULES

Schedules must agree in total with the appropriate item contained in the Financial Statement on page
8 of this report.
Schedule A ─ Marketable Securities
Indicate all debt and equity securities listed on an exchange or otherwise regularly traded in an open market. Separate debt
and equity securities. Securities of closely held corporations should be listed on Schedule D—Proprietary Interests. The
description should include the name of the issuer, the principal amount or number of shares held, and the interest rate, if
applicable. Small holdings may be aggregated and shown as “other” provided that they account for no more than 10 percent
of marketable securities.

Description

Market Value
$

TOTAL

$

Schedule B ─ Notes Receivable
The description should include the name of the obligor, the note's maturity and terms of repayment, and a description of any
collateral. If the note is payable to you and others jointly, indicate only your beneficial interest under Current Balance.
Current
Balance

Description
$

TOTAL

$

10

Schedule C ─ Real Estate and Related Loans
List all real estate in which you hold a beneficial interest. Submit year-end financial statements, including profit and loss
statements, for the last two years for each investment (exclude residence) in which you have an interest equal to 10 percent or
more of your net worth. Also submit a cash flow statement on any investment property valued at 10 percent or more of net
worth.
Description and
Location
(City and State)

Owner of
Property

Percent
Ownership

Mortgage
Holder

Maturity
Date

TOTAL

Current
Market
Value*

Current
Balance**

$

$

$

$

* Carry TOTAL forward to Assets - Real estate
** Carry TOTAL forward to Liabilities - Real estate mortgages

Schedule D ─ Proprietary Interests and Other Securities
List all companies, the shares of which are not listed on a securities exchange or otherwise regularly traded, in which you hold a
beneficial interest. (Submit year-end financial statements, including profit and loss and cash flow statements, for the last two
years for each business interest in which you have an interest equal to 10 percent or more of your net worth.)
Name and Address
of Company

Legal Form
of Company

Nature of Business

Percent
Ownership

Current Value
$

11

TOTAL

$

12

Schedule E - Other Assets
Include retirement funds (for example, 401K, IRA, Keogh), accounts receivable, merchandise and inventory at lower of cost or
market value, machinery and equipment (less depreciation), and life insurance at its cash surrender value.

Description

Basis for Valuation

Current Value
$

TOTAL

$

13

Schedule F ─ Notes Payable and Other Loans
Indicate all loans or notes payable, including loans on life insurance and retirement funds (but not real estate mortgages listed in
Schedule C). Loan origination information must include the original date, loan amount, and co-makers, if any, and their percent
obligation. Small obligations may be aggregated and shown as “other,” provided that they account for no more than 20 percent
of other loans and notes payable. Indicate any debt that is contractually delinquent by an asterisk next to the current balance.

Name and Address of Creditor
and Loan Origination Information

Description and Value of
Collateral

Maturity Date

Current
Balance
$

TOTAL

$

Schedule G - Other Liabilities
Include interest and taxes due and unpaid, other debts accrued, and other liabilities.

Payable To

Description

Maturity Date

Current Balance
$

TOTAL

$

14

Cash Flow Statement*

20____

Sources of Cash
Salaries, wages,
commissions, and other
employment income

20____

Projected Current
Year 20_____

Projected Next
Year 20______

$

$

$

$

$

$

$

$

Rents, royalties, and
investments
Income from dividends and
interest
Income and other
distributions from
partnerships
Other sources**

Total cash received

Uses of Cash
Personal living expenses
(rent, household)
Fixed obligations***
Income taxes
Capital contributions to
partnerships
Other uses**
Total cash outlay

NET CASH FLOW (deficit)

* Discuss any significant changes on a separate page.
** Itemize on a separate page any items amounting to 10 percent or more of total cash received or total cash
outlay.
*** Fixed obligations include debt service on all loans and any budgeted capital improvement expenditures for
real estate investments. Any loan proceeds or debt service related to this transaction should be included in
projections for other sources or uses.

15

Privacy Act Notice
The solicitation and collection of this information, including a Social Security Number, is authorized by those
statutes that require an appropriate federal banking agency to determine the competence, experience, integrity, and
financial ability of individuals proposing to serve a federally regulated financial institution in an official capacity –
that is, as a director, officer, employee, or principal shareholder. These statutes include: 12 U.S.C. § 27
(national bank charters); 12 U.S.C. § 1464 (federal savings bank charters); 12 U.S.C. § 1815 (federal deposit
insurance); 12 U.S.C. § 1817(j) (changes in control of insured depository institutions); and 12 U.S.C. § 1831(i)
(agency disapproval of directors and senior executive officers of insured depository institutions or depository
institution holding companies). The provision of requested information, including a Social Security Number, is
voluntary. However, the failure to provide any requested information may result in denial, disapproval, or delay
in the processing of an application or notice.
Depending on the manner in which an appropriate federal banking agency maintains solicited information, some or
all of that information may be subject to the Privacy Act of 1974, 5 U.S.C. § 552a. In such instances, disclosures
of covered information may be made to: (1) third parties to complete background checks; (2) financial institutions
for supervisory purposes; (3) governmental, tribal, self-regulatory, or professional organizations when information
is relevant to either a known or suspected violation of law or licensing standard or relevant and necessary to the
governmental or self-regulatory organization’s regulation or supervision of financial service providers; (4) the
Department of Justice, a court, an adjudicative body, a party in litigation, or a witness when relevant and
necessary to a legal or administrative proceeding; (5) congressional offices when the information is relevant to an
inquiry initiated on behalf of its provider; (6) an agency’s contractors or agents; and (7) other third parties when
mandated or authorized by statute.
Additionally, while certain of the solicited information is exempt from disclosure under the Freedom of
Information Act because disclosure would constitute a clearly unwarranted invasion of personal privacy, other
information is not exempt. Nonexempt information will ordinarily include the names of individuals, the financial
institutions that they propose to serve, the statutory context in which information has been provided, and prior
bank-related employment and affiliation.

CERTIFICATION
*If a joint financial statement is being submitted, both parties should complete the “Certification.”

I understand that the appropriate regulatory agency may conduct extensive checks into my
background, experience, and related matters in conjunction with my application or filing.
I certify that the information contained in the biographical report and financial report,
including all attachments, has been carefully examined by me and is true, correct, and
complete. 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 U.S.C. §§ 1001
and 1007.
Signed this

day of

,

.
________________________________
Signature*
________________________________
Print or type name
________________________________
Title (if applicable)

Signature
Print or type name
Title (if applicable)
16