Form OTS Form 1661 OTS Form 1661 Minority Thrift Certification Form

OMB Control No. 1550-0096

OFFICE OF THRIFT SUPERVISION

MINORITY THRIFT CERTIFICATION FORM

The Office of Thrift Supervision will use this information to maintain accurate records on the identity of minority-owned thrifts. Collection of the information is voluntary. Public reporting burden for this collection of information is estimated to average .50 hours per response, including the time for reviewing instructions and completing and reviewing the collection of information. If a valid OMB Control Number does not appear on this form, you are not required to complete this form. Send comments regarding this burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to Community Affairs, Office of Thrift Supervision, 1700 G Street, N.W., Washington, D.C. 20552; and to the Office of Management and Budget, Paperwork Reduction Project (1550-0096), Washington, D.C. 20503.

For Calendar Year ____

1. NAME AND ADDRESS OF SAVINGS INSTITUTION:

(include city, state and zip code)

DOCKET NO.: TELEPHONE NO.:

2. CHIEF EXECUTIVE OFFICER:

CHAIRMAN OF THE BOARD:

3. NAME AND ADDRESS OF HOLDING COMPANY (if applicable):

4. PERCENTAGE OF THRIFT STOCK THAT IS OWNED BY THE HOLDING COMPANY: %.

5. IF A STOCK INSTITUTION, PLEASE PROVIDE THE FOLLOWING INFORMATION (IF THE THRIFT IS OWNED BY A HOLDING COMPANY, PROVIDE THE INFORMATION AS IT APPLIES TO THE HOLDING COMPANY):

• TOTAL NUMBER OF SHARES OUTSTANDING:

• NUMBER OF SHARES OWNED BY EACH OF THE FOLLOWING GROUPS:

African Americans:

Hispanic or Latino Americans:

American Indians or Alaskan Natives:

Asian/Pacific Islander Americans:

Women:

Widely held-ownership not known:

• TOTAL NUMBER OF SHARES OWNED BY MINORITIES:

• PERCENTAGE OF SHARES OWNED BY MINORITIES:

6. IF A MUTUAL INSTITUTION:

• TOTAL INDIVIDUALS ON THE BOARD OF DIRECTORS:

• TOTAL MINORITIES ON THE BOARD OF DIRECTORS (please identify minority type from the list in no. 5):

• PERCENTAGE OF BOARD OF DIRECTORS THAT ARE MINORITIES:

• NUMBER OF DEPOSIT ACCOUNTS:

• PERCENTAGE OF DEPOSIT ACCOUNTS OWNED BY MINORITIES (please
  identify minority type from the list in no. 5):

7. Briefly describe how the institution is serving the convenience and needs of the local minority community in which it is chartered to do business.

8. Please provide a central point of contact at your institution for the OTS Minority Owned Institution Program.

Name: Telephone No.:

Email:

I hereby certify that all of the information provided herewith is true and accurate and I understand that any misrepresentation of fact is subject to the provisions of Title 18, Section 1001 of the United States Code.

Signature ________________________________

T

AFFIX SEAL

itle ____________________________________

Date _____________________________________

OTS Form 1661

Revised December 2007