Notice of Change in Chief Executive Officer or Director

OMB No. for OCC 1557-0014

Expires

NOTICE OF CHANGE IN CHIEF EXECUTIVE OFFICER OR DIRECTOR

Public reporting burden for the collection of information in this Notice is estimated to average 1 hour per response, including the 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: Licensing Activities Division, Licensing Department, Comptroller of the Currency, 250 E Street, SW, Washington, DC 20219; 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.

This is an After-the-Fact Notice filed pursuant to 12 CFR 5.50(h).

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Name of Depository Institution Charter No.

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Street County

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City State Zip Code

Full Name of Individual: ___________________________________________

Notice to serve as a:  Director

• Chief Executive Officer

Reason:  To replace ; or

(Name of individual)

 To fill a new position.

Date Service Began: _______________________

1. Describe the steps taken by the depository institution to investigate and satisfy itself as to the competence, experience, character, and integrity of the subject individual.

2. Summarize the individual's qualifications for the position. Include a statement of the past and current business and professional affiliations.

Privacy Act Notice

A copy of this document is provided to the Comptroller of the Currency (OCC) as required under 12 U.S.C. 1817(j) and 12 CRF 5.50(h). To the extent that it contains personal and financial information concerning directors or the chief executive officer of a depository institution, the information may be subject to the Privacy Act of 1974 (5 U.S.C. 552a) concerning safeguarding personal information.

This information is required to enable the OCC to evaluate each proposed addition of any individual to the board of directors or the employment of any individual as a chief executive officer and determine whether or not to disapprove it. A failure to provide this information could result in objection to such a proposal because notice has not been satisfied. This document is a public document and may be available to the public upon request under the provisions of the Freedom of Information Act (5 U.S.C. 552). Contact the OCC for the specific procedures under which the document would be disclosed to the public and its treatment of confidential information.

CERTIFICATION

I certify that the information provided in this Notice has been carefully examined by me and is correct, complete, and made in good faith. 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 , 20 .

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Signature of Authorized Representative

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Name and Title of Authorized Representative

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(Area Code)(Telephone Number)

____________________________

(E-mail Address)

__________________

(Fax Number)

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