Form 6710/07 Application Pursuant To Section 19 Of The Federal Deposi

Paperwork Reduction Act Notice for Application For Deposit Insurance FDIC 6710/07.
The OMB number (3064-0018) and the curent expiration date must be displayed on the
face of the form. The notice below may be displayed on the form or on the instructions
to the form. Until the current form is revised, staple the language of
the paragraph below
onto the top of the form.

Paperwork Reduction Act Notice: The FDIC may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless it displays a currently
valid OMB number. Section 19 ofthe Federal Deposit Insurance Act (12 U.S.c. § 1829)
requires the FDIC's consent prior to any paricipating in the affairs of an insured
depository institution by a person who has been convicted of crimes involving dishonesty
or breach oftrust.An insured depository institution that desires to obtain the FDIC's
consent must submit an application to the FDIC on Form FDIC 6710/07. The estimated
burden for this collection is 16 hours per response. Send comments regarding this bl.den
estimate or any other aspect of
this collection, including suggestions for reducing,.this
burden, to the Assistant Executive Secretary (Regulatory Analysis), Offce of
the
Executive Secretar, Federal Deposit Insurance Corporation, 550 1 ih Street, N.W.,
Washington, D.C. 20429.

PRIVACY ACT STATEMENT
Form FDIC 6710/07, Application Pursuant to Section 19 of

Pursuant to Section 19 of

the Federal Deposit Insurance Act, 12 U.S

the Federal Deposit Insurance Act

,C. § 1

829(a), persons

convicted of certain criminal offenses are prohibited from participating in the affairs of an insured
depository institution without the express wrtten consent of the FDIC. This prohibition applies
to any person convicted of a criminal offense involving dishonesty or breach of trst or money

laundering or who has entered into a pretral diversion or similar program in connection with a
prosecution for such offense. In the absence of prior FDIC approval, such persons are prohibited
from being directly or indirectly affliated with an insured depository institution; owning or
controlling an insured depository institution; or otherwise directly or indirectly participating in
the conduct of the affairs of an insured depository institution. Insured depository institutions are
also prohibited from permitting such persons from engaging in any of the aforementioned
activities.
The FDIC wil evaluate the information ,provided in this Application in accordance with the
policy announced in FDIC Financial Institutions Letter 125-98 (December 2, 1998),
statement of
Your Social Security Number (SSN) is requested for us in verifying the accuracy of the
information in this Application and to differentiate you from other prospective directors, offcers,
or employees with similar or identical names. The collection of this information is authorized
pursuant to 12 U.S. C. § 1819 and Executive Order 9397. Although providing your SSN and
pertinent information may adversely
other requested information is voluntary, your omission of
affect the assessment of your Application.
The information collected in the Application wil be maintained as par of

the FDIC System of

Records #30-64-000, "Financial Institutions Investigative and Enforcement Records." This

information may be disclosed in accordance with the applicable routine uses set forth in the
Records. This may include disclosure to (1) A cour, magistrate, or
the System of

Notice of

administrative tribunal in the course of presenting evidence, including disclosures to counselor

witnesses in the course of civil discovery, litigation, or settlement negotiations or in connection
with criminal proceedings, when the FDIC is a part to the proceeding or has a significant interest
in the proceeding and the information is determined to be relevant and necessary; (2) The
appropriate Federal, State, or local agency or authority, or to licensing boards, professional
associations or administrative bodies responsible for investigating or prosecuting a violation of or
for enforcing or implementing a statute, rule, regulation, or order when the information indicates
a violation or potential violation of law, rule, regulation or order, whether civil, criminal, or
regulatory in natue, and whether arising by general statute or particular program statue, or by
regulation, rule, or order issued pursuant thereto; (3) A congressional office in response to an
inquiry made by the congressional offce at the request of the individual to whom the record

pertains; (4) A financial institution affected by enforcement activities or report criminal activities;
(5) Other Federal, State, or foreign financial institutions supervisory or regulatory authorities; (6)
A consultat, person, or entity who contracts or subcontracts with the FDIC, to the extent

necessary for the performance of the contract or subcontract; and (7) The Departent of the
Treasury, federal debt collection centers, other appropriate federal agencies, and private
collection contractors or other third parties authorized by law, for the purpose of collecting or
assisting in the collection of delinquent debts owed to the FDIC.

FEDERAL DEPOSIT INSURANCE CORPORATION

APPLICATION PURSUANT TO SECTION 190F THE FEDERAL DEPOSIT INSURANCE ACT
SECTION A. APPLICANT BANK INFORMATION

1, NAME OF BANK
12' DATE OF APPLICATION

3, ADDRESS OF BANK (Street, City, County, State and zip Code)

We heve, in connection with this Requllt, read the following provision of the Federal Deposit Insurance Act which governs requests by insured banks for the

the Bank, of a parson who has been convicted of a crima involving dish~nesty

consent of the Fedaral Daposit Insurance Corporation to the employment, by

or breach of. trUst, namely:

"Section 19. Except with the written consent of the .Corporation, no person shall serve as a director, offcer, or employee of an insured

bank
who has been convicted, or who is hereafter convicted, of any criminal offense involving dishonesry or a breach of trust. For each willful
violation of this prohibition, the bank involved shall be subject to a penalty of not more than $100 for each day this prohibition is violated;
which the Corporation may recover for its use."
In support of this Requllt, the following statements, representations end Information are submitted for the

purpose of Inducing' the Federal Deposit

Insurance Corporation to grant its written consent to the service as a director, officer, or employee of the bank, a person who has been

Involving dishonestY or a breach of trust: '

convicted of a crime

SECTION B. BIOGRAPHICAL INFORMATION CONCERNING THE PROSPECTIVE DIRECTOR, OFFICER, OR EMPLOYEE

1, NAME 2. ADDRESS (Street, Ciry, State and ZiP Code)
3. .DATE OF BIRTH (Mo., Day, Yr.)

4. PLACE OF BIRTH (City and State)
5. SOCIAL

SECURITY NUMBER

6. NAME AND ADDRESS OF PRESENT OR MOST RECENT EMPLOYER (Street, City, State and ZiP Code)

7. INDICATE TOTAL NUMBER OF VOTING SHARES OF THE BANK'S STOCK DIRECTLY OR INDIRECTLY OWNED OR OTHERWISE CONTROL.
LE D. (Answer "none" if appropriate.)

SECTION C .

1.

DESCRIPTION OR NATURE OF CRIME
(al

INFORMATION RELATIVE TO CONVICTIONISI
DATE OFCONVICTION
(bl

NAME AND ADDRESS OF COURT
leI

DISPOSITION
ldl

NOTE; If additional convictions for crimes involving dishonesty or breach of trust are discovered subsequent to approval of this request, ano ther request may
be necessary.

2. Brieflydescribe the nature of the offense and the circumstances surrounding it. Include age of prospective employee at the time of conviction, date of the

offense, and eny mitigeting circumstances (parole, suspension of sentence, pardon, etc.).

3. Briefly describe the extent of rehabilitation of the prospective director, officer, or employee and attach supporting documents, if any.

FDIC 6710/07 (Page Two)

OMB No.: 3064.0018
Federal Deposit Insurance Corporation Expira~q¡~!~~~~i

CORPORATION GUIDELINES AND POLICIES WITH RESPECT TO SECTION 19 (. IL..Lt7VV I
.Public reporting burden for this collection of Information Is estimated to average 16

hours per response, Including the time tor reviewing Instructions, searchln,
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding this burdar

.estlmate or any other aspect of this collection of Information, Including suggestions lor reducing this burden, to the

Assistant Executive Secretary (Administration)
Room 6096, FDIC, Washington, DC 20429; and to the Office .of Management and Budget, Paperwork Reduction Project
(3064.0016), Washington, DC 20503.

On September 27, 1968, the Federal Deposit I nsu ranee Corporation's Chairman addressed the

following memorandu m to ali

insu red banks.

;'The Federal Deposit Insurance Corporation has for some time been studying in detail Section 19 of the Federal Deposit Insurance
Act (12 U.S.C. 1829), relating to the requirement for this Corporation's consent prior to any insured bank employing persons who have

been convicted of cri mes involving dishonesty or breach of trust.
"Section 19 provides

as follows:

'Except with the written consent of the Corporation no person shall serve as a director, officer, or employee of an insured
bank who has been convicted, or who is hereafter
convicted of any criminal offense jnvolving dishonesty or breach of trust.
For each willfu I violation of this proh ibition, the bank involved shall be subject to a penalty of not more than$ i 00 for each
day this prohibition is violated, which the Corporation may recover for its use.'
"Since the enactment of this law in 1950, our Board has reviewed cases coming under it on an ad hoc basis'and each case has been

judged on its own merits according to the particular facts and circumstances involved, The need for guidelines 'ánd standards to be applieo
prospectively has increased in recent years. I nqu iries continue to come in from banking institu tions ask ing what standards shou Id be
applied by them in determining whether an application under Section 19 is required. In addition, programs are now underway on both
the Federal and state levels to hire and retrain the hardcore unemployed, some of whom may have criminal records, and the banking

community will no doubt participate in these programs to some .degree. For these reasons, the Board of Directors has adopted the
following general guidelines and policies with respeCt to Section 19. It is our hope that these guidelines will beof assistance to all banks
having questions concerning the applicability of our law, and that they will, at the same time, serve to insure the continuing stability and
confidence in our banking system."

i. STANDARDS TO BE APPLIED IN DETERMINING WHETHER AN APPLICATION FOR CONSENT IS REQUIRED UNDER
SECTION 19
A. There must be present a convict

jon of record. Arrests,. pending cases not brought to trial, acquittals,

has been reversed on appeal will be excluded from the requirements of Section
19. A
Section 19 application until or

unless otherwise reversed.

"Or any conviction which

conviction which is being appealed will require a

B. The conviction must be for a crjmin81 offense involvjng dishonesty or breach of trust. Felonies as well as misdemeanors wherein
dishonesty or breach of trust is involved are included within the definition. Dishonesty is defined to mean "to cheat or defraud for

monetary gain or its equivalent, directly or indirectly, or to wrongfully take from any person, property lawfully belonging to thatperson
in violation of any criminal statute or code." ¡Acts of dishonesty are further defined to include, but not limited to, such acts which

involve want of integrity, lack of probity, or involve a disposition to distort, defraud, cheat or to act deceitfully or fraudulently.
dishonesty may also include crimes which by federal or state criminal statutes and codes are defined as dishonest.) Breach
respect to any property or fund which has been lawfully

Furthermore,

of trust is defined to mean "a wrongful use, misappropriation, or omission with

committed to a person in a fiduciary capacity,"
C. Youth Offenders

1. Adjudgment by a court against a person as a "youthful offender" under any youth offender law or adjudgement as
a "juvenile delinquent" by a family court or any other court having jurisdiction over minors as defined by state law

will not require an application under Section 19. Such adjudications are not considered convictions for criminal

offenses.

D. Adults and All Minors Convicted of Crimes
1. The conviction of any adult or minor by a court of competent jurisdiction for any criminal offense involving dishonesty or breach of trust as defined in paragraph B above will require an application

employment of that person.

for consent prior to a bank's

II. THE CORPORATION'S POLICY WITH RESpECT TO APPLICATIONS MADE UNDER SECTION 19

A. In considering any application made by an insured bank to employ a person who has been convicted of a criminal offense in.
volving dishonesty or breach of trust, the factors to be considered will include but will not be limited to the following:
1. The specific nature of the offense involved and the circumstances surrounding It.

2. The evidence of rehabilitation of the person since the dale of hlslher conviction (parole, suspension of sentence, and reputation
of the person since conviction will be given consideration. Participation by the person In programs on the national or

to hire and retrain the hard -core unemployed also will be given consideration.
3. The age of the person at the time of hls/her conviction.

state levels

4. The position lobe held by the person In the bank.

5. The fidelity bond coverage applicable (or to be applicable) to the person:'
CORPORATION STATEMENT OF POLICY

The Board of Directors of the Federal Deposit i nsurance Corporation approved the following statement of policy at its offices ir
Wa.h ingtcfl, D.C., on the 21 st day of September, 1976:

\
Tile Corporation does not view Section 19 as being punitive in intent. Rather, the
criterion
assessing
suchof
application!
is whether the prospective director, officer, or employee constitutes a significant threat oressential
risk to the
safetyinand
soundness
the appli.
cant bank, and

our policy is to approve applications in which this risk is absent. .

tive employee. !

Existing Corporation policy on Section 19 applications has involved consideration ofthe nature and circumstances of the offense
the evidence of rehabilitation, the position to be held by the employee in the bank and the applicability of the bank's fidelity bone

coverage to the employee. These remain important considerations in determining the risk to the bank in the employment of the prospec

On this basis, many applications can be routinely approved because the prospective employee will not be in a position to constitute
and soundness of the bank. Employees who will occupy clerical, maintenance, or service positions or, in
many banks, administrative or teller positions generally pose no such risk, and on application from the board of directors of the bank,
any substantial risk to the safety

nOrmally will be able to be routinely approved. A more detailed analysis will be required in the case of directors, officers, or other

ployees in a position to control or influence the disposi.tion of sums of money large in relation to the size of the bank.
FDIC 6710/07 (6.91) (Page One)

em.

4,' Altae;, copill of the Indictment, Information, or Complaint and Final Decree of

reasons for unavailability),

the court. If not provided, explain

Judgment, if available; (Normally these can be obtained from t,he clfJri( of

,"

5, List any other pertinent facts relative to the crime which are not disclosed in the indictment.

I do

hereby cenify that the Biographical Information (Section BI and Information Relative to Conviction (Section C) are truH and corr~ctto the best of my

knowledge and belief.

SIGNATURE OF PROSPECTIVE DIRECTOR, OFFICER OR EMPLOYEE DATE SIGNED
NOTE: The information requested in Sections Band C above, including the Social Security Number of the prOSPBctiv.e director, officer or

employee, is

solicited pursuant to Section 19 of the Federal Deposit Insurance Act (12 U.S.C. §18291. This information Is necessary

to assist tha FDIC in
any appropriate
Federal or State bank regulatory agency and, law enforcement or other governmental agencies for Identity viìriflcatlon pUrposes. Should
the
information indicate a violation of law,the epplication may be referred to any agency responsible for Investigating or prosecuting such a violation.
assessing the merits of the application. Some of the information, including the Social SecuritY Number, may be provided to

In addition, in the eveni of litigation, the application may be presentEK to the appropriate court as evidence and to counsel In .the courSe of
discovery. While submission .of the information is voluntary, an omission or inaccuracy may result either in

delay. inoffièeror
processing
the application
or In
a denial of the applicetlon. Falsification of any of the in;ormation may sarve as a basis for removal of the director,
employee
If employed
by the bank and as grounds for criminal charges.
SECTION D. POSITION TO BE OCCUPIED BY THE PROSPECTIVE DIRECTOR, OFFICER OR EMPLOY~E
1. TITLE OF POSITION (51
2. Describe the

duties and responsibilitiM of the prospectiVe director, officer or employee.

Include extent of supervision exercisedovar others and/or by others.
..,

NOTE: Should this request be approved, any significant change in

the duties and/or responsibilities of
the prospective dIrector, officer or employee which
occurs within 12 monrhs subsequent to such approval must be reported in writing to the Regional Director of the Federal Deposit Insurance CorpOl7tion

Region in which the bank isìocated.
SECTION E . NOTIFICATION OF

FIDELITY INSURER

The bank's fidelity insurer is to be notified of all pertinent Information regarding the conviction of the prospective employee. Assrances from the fidelity
insurer must be

obtained, in writing, stating that the prospective director (If applicable), officer, or employeø will be cov.er.sd bV the bank's fidelity bond.

This application and the inforrnationreQuested herein may be submitted prior to notification of the bonding company: however, the Corporation's
will be subject to a condition that written assurance off.idelity.cov.erage to the same extent

as others in similar positions be obtained by the bank.

consent

ADDITIONAL INFORMATION IN SUPPORT OF THIS REQUEST

SECTION F .

List any other appropriate information,

I do heraby certify that the Board of Directors
applications pursuant to.

Section

adopted a res.olution which delegated

the undersigned the authority to make
authorizing this applica.

19 of tha Federal Deposit Ir)surance Act or has adopted a resolution

tion pursuant to Section 19 of the Federal Deposit Insurance

Act.

SIGNATURE OF BANK OFFICIAL

This Is an official document of the Federal Deposit Insurance Corporation. Providing false Information may be grounds for prosecution under the provisions
of Title 18, Section 1001 Ot 1007 of the United

FDIC 6710/07

(Page ThrtNl

States Code and may be punishable by fine or Imprisonment,