Form FDIC-2120/16 Applicant Certification Statement

PRIVACY ACT NOTICE

AUTHORITY: Collection of this information is authorized by Executive Order 9397 and by section 12(f)(4) of the Federal Deposit Insurance Act, 12 U.S.C. § 1822(F)(4) as amended by section 19 of Public Law 103-204. The information requested on this form will be used to determine your eligibility for employment with the Federal Deposit Insurance Corporation (FDIC). The information may be disclosed outside the FDIC in accordance with the routine uses listed below. Your social security number (SSN) is requested to ensure that our records are accurate since other people may have the same name or birth date. Your completion of this form, including the provision of your SSN, is voluntary; however, your application cannot be processed, and you will be ineligible for employment with the FDIC, if you do not provide the requested information.

PRIVACY ACT ROUTINE USES

This record and information in this record may be used in disclosing information:

- To designated officers and employees of agencies, offices, and other establishments in the executive, legislative, and judicial branches of the Federal Government, having a need to evaluate qualifications, suitability, and loyalty to the United States Government and/or a security clearance or access determination

• To designated officers and employees of agencies, offices, and other establishments in the executive, legislative, and judicial branches of the Federal Government, and the District of Columbia Government, when such agency, office, or establishment conducts an investigation of the individual for purposes of granting a security clearance, or for the purpose of making a determination of qualifications, suitability, or loyalty to the United States Government, or access to classified information or restricted areas;

• - To designated officers and employees of agencies, offices, and other establishments in the executive, judicial, or legislative branches of the Federal Government having the responsibility to grant clearances, to make a determination regarding access to classified information or restricted areas, or to evaluate qualifications, suitability, or loyalty to the United States Government in connection with performance of a service to the Federal Government under a contract or other agreement;

• To intelligence agencies for use in intelligence activities;

• To any source from which information is requested in the course of an investigation, to the extent necessary to identify the individual, inform the source of the nature and purpose of the investigation, and to identify the type of information requested;

• To the Federal, State, or local agency responsible for investigating, prosecuting, enforcing, or implementing a statute, rule regulation, or order where there is an indication of a violation or potential violation of civil or criminal law or regulation;

• To an agency, office or other establishment in the executive, legislative, or judicial branches of the Federal Government, or the District of Columbia Government, in response to its request, in connection with the hiring or retention of an employee, the issuance of a security clearance, the conducting of a security or suitability investigation of an individual, the classifying of jobs, the letting of a contract, or the issuance of a license, grant, or other benefit by the requesting agency;

• To Federal agencies as a data source for management information through the production of summary descriptive statistics and analytical studies in support of the functions for which the records are maintained or for related studies;

• To a Congressional Office in response to an inquiry made at the request of that individual;

• In litigation before a court or in an administrative proceeding being conducted by a Federal agency;

• To the National Archives and Records Administration for records management inspections;

• To the Office of Management and Budget in connection with private relief legislation;

• To respond to a request for discovery or for appearance of a witness; and

• To the Merit Systems Protection Board, the Office of Special Counsel, the Equal Employment Opportunity Commission, or the Federal Labor Relations Authority, in connection with functions vested in those agencies.

ESTIMATED REPORTING BURDEN

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17^th Street, N.W., Washington, DC 20429; and to the Office of Management and Budget, Paperwork Reduction Project (3064-0121), Washington, D.C. 20503. An agency may not conduct nor sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

FRAUD OR FRAUDULENT STATEMENT NOTICE

Falsification of any answer may result in a fine of not more than $10,000 or imprisonment for not more than 5 years or both

(18 U.S.C. § 1001)

DEFINITIONS

1. “Felony” is any violation of law punishable by imprisonment of longer than one year, except for violations called misdemeanors under state law which are punishable by imprisonment of two years or less.

2. “Company” is any individual, corporation, partnership, joint venture, business trust, association or similar organization, or any other trust unless by its terms it must terminate within 25 years or not later than 21 years and ten months after the death of individuals living on the effective date of the trust, but shall not include any corporation the majority of the shares of which are owned by the United States, any state, or the District of Columbia.

3. “Control” means:

a. The power to vote, directly or indirectly, 25 percent or more of any class of the voting stock of a company, the ability to direct in any manner the election of a majority of a company’s directors or trustees, or the ability to exercise a controlling influence over the company’s management and policies. For purposes of this definition, a general partner of a limited partnership is presumed to be in control of that partnership.

b. An entity or individual shall be presumed to have control of a company if the entity or individual directly or indirectly, or acting in concert with one or more entities or individuals, or through one or more subsidiaries, owns or controls 25 percent or more of its equity, or otherwise controls or has power to control its management or policies.

4. "Default on material obligation" is a loan or advance from an insured depository institution which is or has been delinquent

for 90 or more days as to payment of principal and/or interest.

5. “Insured depository institution” is any bank or savings association the deposits of which are insured by a Federal Deposit Insurance Fund administered by the FDIC.

6. “Pattern or Practice of Defalcation regarding obligations” means:

a. A history of financial irresponsibility with regard to debts owed to insured depository institutions which are in default in excess of $50,000 in the aggregate. Examples of such financial irresponsibility include, without limitation:

(1) Failure to pay a debt or debts totaling more than $50,000 secured by an uninsured property which is destroyed; or

(2) Abuse of credit cards or incurring excessive debt well beyond the individual's ability to repay resulting in default(s) in excess of $50,000 in the aggregate.

b. Wrongful refusal to fulfill duties and obligations to insured depository institutions. Examples of such wrongful refusal to fulfill duties and obligations include, without limitation:

(1) Any use of false financial statements;

(2) Misrepresentation as to the individual's ability to repay debts;

(3) Concealing assets from the insured depository institution;

(4) Any instance of fraud, embezzlement or similar misconduct in connection with an obligation to the insured depository institution; or

(5) Any conduct described in any civil or criminal judgment against an individual for breach of any obligation, contractual or otherwise, or any duty of loyalty or care that the individual owed to an insured depository institution.

7. “Substantial Loss to Federal Deposit Insurance Funds” is :

a. A loan or advance from an insured depository institution, which is now owed to the Federal Deposit Insurance Corporation (FDIC), Resolution Trust Corporation (RTC), Federal Savings Loan Insurance Corporation (FSLIC) or their successors, or any Federal deposit insurance fund, that is delinquent for ninety (90) or more days as to payment of principal, interest, or a combination thereof and on which there remains a legal obligation to pay an amount in excess of $50,000;

b. A final judgment in excess of $50,000 in favor of any Federal deposit insurance fund, the FDIC, RTC, or FSLIC, or their successors regardless of whether it becomes forgiven in whole or in part in a bankruptcy proceeding;

c. For purposes of computing the $50,000 ceiling above, all delinquent judgments, loans, or advances currently owed to the FDIC, RTC, FSLIC, or their successors, or any Federal deposit insurance fund, shall be aggregated. In no event shall delinquent loans or advances from different insured depository institutions be separately considered.

Federal Deposit Insurance Corporation APPLICANT CERTIFICATION STATEMENT		NAME
		     
		SOCIAL SECURITY NUMBER
		*** - ** -     
Federal Deposit Insurance Corporation Certification of Compliance with Section 12(f)(4) of the Federal Deposit Insurance Act (12 U.S.C. § 1822(f)(4)) as amended by Section 19 of Public Law 103-204 NOTICE: Furnishing the information requested on this form is a condition of employment for all applicants prior to appointment with the Federal Deposit Insurance Corporation. Please read the Privacy Act Notice, Privacy Act Routine Uses, and the definitions on page 2 of this form before answering the following questions. If you wish to discuss any of the definitions or questions on this form prior to submission you may seek guidance from the Ethics Unit, Legal Division, telephone (202) 898-7287. The Federal Deposit Insurance Corporation is prohibited by statute from employing any person who does not meet minimum competence, experience, integrity, and fitness requirements. No person shall become employed performing the responsibilities of or for the Federal Deposit Insurance Corporation who must respond YES to any of the following questions. Further, you are advised that the Federal Deposit Insurance Corporation cannot retain employees who are not in compliance with the prohibitions listed in Part I, below, anytime after June 17, 1994.
PART I – EMPLOYMENT REQUIREMENTS
			YES	NO
1. Have you been convicted of a felony?			   	   
2. Have you been removed from, or prohibited from participating in the affairs of, any insured depository institution(s) pursuant to any final enforcement action by any federal banking agency?			   	   
3. Have you demonstrated a pattern or practice of defalcation regarding obligations to insured depository institutions?			   	   
4. Have you caused a substantial loss to federal deposit insurance funds?			   	   
PART II – INFORMATION ON DEFAULTS
Any candidate for employment shall submit a list and description of all instances during the five (5) years preceding the submission of an application for employment in which the person or a company under such person’s control defaulted on a material obligation to an insured depository institution. Provide complete information regarding any default, include the total dollar amount, financial institution, dates, and final judgment or current status of the obligation on a separate page, and attach in duplicate to this form, including your name, Social Security Number, and original signature on each page of the attachment. Please check the appropriate box below: I have not defaulted on a material obligation or caused any loss as defined on the reverse within the last 5 years; therefore, I have not prepared an attachment. I have attached details regarding all defaults in the preceding 5 years.
PART III – CERTIFICATION
I certify that I have read the definitions, which are a part of this form, and that the statements I have made on this certification are true, complete, and correct to the best of my knowledge and belief. During the term of any employment I may have with the Federal Deposit Insurance Corporation, I will immediately provide the Ethics Unit with a written explanation of any facts or circumstances which would cause these answers to change.
Signature of Applicant	Date	Identify Announcement Number for which you have applied, or Position Title, Grade, and Organizational Location:
	     	     

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