Form 1624 Interagency Notice of Change in Director or Senior Execu

OMB No. for FDIC
OMB No. for FRB
OMB No. for GCC
OMB No. for OTS
Expiration Date:

3064-0097
7100-0134
1557-0014
1550-0047
0 l/3 l/2000

INTERAGENCY NOTICE OF CHANGE
IN DIRECTOR OR SENIOR EXECUTIVE OFFICER
Public reporting burden for the collection of information in this Notice is estimated to average 2 hours 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: Offrce of the Executive Secretary, Federal Deposit
Insurance Cotporation, 550 17th Street, NW, Washington, DC 20429; Secretary, Board of Governors ofthe Federal Reserve System, 20th and C Streets,
NW, Washington, DC 20551; Licensing Policy and Systems Division, Comptroller ofthe Currency, 250 E Street, SW, Washington, DC 20219; or
Corpomte Activities Division, 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
Who Must File
This Notice is used, as required by Section 32 of the Federal Deposit Insurance Act (Act) (12 U.S.C. 183 li), by a depository
institution or its holding company to notify the appropriate regulatory agency of a proposed change in the board of directors
or senior executive officer of such institution or holding company.
In general, this requirement

is applicable to a depository institution or depository institution holding company that:

is not in compliance with all minimum capital requirements applicable to such institutionas determined by the
appropriate regulatory agency on the basis of such institution or holding company’s most recent report of condition,
report of examination or inspection;
is in troubled condition; or
the appropriate regulatory agency determines, in connection with its review of a capital restoration plan required under
Section 38 of the Act (12 U.S.C. 183 lo) or otherwise, that such prior notice is appropriate.

Preparation
The depository institution or its holding company (filer) should complete this Notice by providing a response to each of the
questions and signing the Certification for each proposed individual. Information should be provided as of the Notice’s
submission date. In addition, each proposed individual must complete the biographical and certification portions of the
Interagency Biographical and Financial Report. The filer and each proposed individual are responsible for understanding
the requirements and the accuracy of the statements. The completed form(s) should be sent to the appropriate regulatory
agency.
For additional information regarding the processing procedures and guidelines and any supplemental information that may
be required, please refer to the appropriate regulatory agency’s procedural guidelines (i.e., ComDtroller’s CorDorate Manual,
the FREYProcessing ADDlications Through the Federal Reserve System and the Audications Procedures Manual, the FDIC’s
Rules and Regulations (12 C.F.R. 303.14) and relevant policy statements, or the OTS’ ADDlication Processing Handbook)
or contact the agency directly for specific instruction.

Confidentiality
In general, requests for confidential treatment of specific portions of the application must be submitted in writing
concurrently with the submission of the application and must discuss the justification for the requested treatment. Applicant’s
reasons for requesting confidentiality should specifically demonstrate the harm (e.g., to its competitive position, invasion
of privacy) that would result from public release of information (5 U.S.C. 552). Information for which confidential treatment
is requested should be (1) specifically identified in the public portion of the application (by reference to the confidential
section); (2) separately bound; and (3) labeled “Confidential.”
Applicant should follow the same procedure regarding a
request for confidential treatment with regard to the subsequent filing of supplemental information to the application.
An Applicant should contact the appropriate regulatory agency for specific instructions regarding requests for confidential
treatment. The appropriate regulatory agency will determine whether the information submitted as confidential will be so
regarded and will advise the Applicant of any decision to make available to the public information labeled as “Confidential.”

INTERAGENCY NOTICE OF CHANGE
IN DIRECTOR OR SENIOR EXECUTIVE OFFICER
Details of Proposed Transaction

Full Name of Individual
Notice to serve as a:

Cl
cl

Director
Senior Executive Officer (

)
(Title)

Reason:

Type of filing:

q

To replace

q

(Name of individual)
To fill a new position.

cl

Prior Notice

; or

Cl After-the-Fact

Notice

El Waiver Previously Granted

Name of Depository Institution or Holding Company

county

Street

State

City

Zip Code

1. Describe the steps taken by the depository institution or holding company to investigate and satisfy itself as to the
competence, experience, character, and integrity of the subject individual. Summarize the individual’s qualifications for
the proposed position.

2. If this Notice represents a proposal to serve as a senior executive officer of a depository institution or holding company:
(a)

Describe the duties and responsibilities

of the subject position or attach a position description, if applicable.

(b)

Discuss the proposed terms of employment of the subject individual and attach a copy of all pertinent documents,
including any applicable employment contract or compensation arrangement.

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Privacy

Act Notice

A copy ofthis document is provided to the appropriate regulatory agency as required under Section 32 of Federal Deposit Insurance Act (12 U.S.C. 183 li).
To the extent that it contains personal and financial information concerning proposed directors or senior executive officers of a depository institution or
holding company, 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 appropriate regulatory agency to evaluate each proposed addition of any individual to the board of directors or
the employment of any individual as a senior executive officer and determine whether or not to disapprove it. A failure to provide this information could
result in disapproval of such a proposal or a determination that the legal requirement of prior 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 appropriate
regulatory agency for the specific procedures under which the document would be disclosed to the public and its treatment of confidential information.

CERTIFICATION
I cert@ that the information provided in this Notice has been carefully examined by me and is correct, complete, and made
in good faith. The biographical information included in the attached Interagency Biographical and Financial Report has
been reviewed, and it is consistent with the information obtained by the depository institution or holding company. 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

1-.

Signature of Authorized Representative

Name and Title of Authorized Representative

(Area Code)(Telephone

Number)

(Fax Number)

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