Form 3170-XXXX Nomination Form

OMB#3170-XXXX

APPLICATION TO SERVE ON

ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP

Consumer Financial Protection Bureau

You are being considered for a position as a representative on an Advisory Board, Body, Panel, Committee or other similar group (generally, “Advisory Group”) of the Consumer Financial Protection Bureau (CFPB). Please complete and submit this questionnaire as part of the application and selection process for the Advisory Group. CFPB will use this information to perform a background check, conduct a conflict of interest review, and perform other similar due diligence activities associated with your application and possible selection as a representative on the Advisory Group. CFPB will use the information you provide only for these purposes or other purposes authorized by law, and will not disclose it unless required by law. (See the Privacy Act Notice.) Please ensure that the information you provide is complete and accurate.

BACKGROUND INFORMATION

Name of Advisory Group to which you are applying to be a representative
Name (Print last, first, middle initial)				E-mail Address
Position/Title			How long at employer?
Employer	Address
Work Phone	Cell Phone				Other
Place of Birth		Date of Birth				Social Security Number
List your business experience.
List education and any specialized experience.
List other affiliations and/or service as a community leader that would benefit you in your role as a member of the advisory group.
List any Federal advisory committee or any board on which you are currently a member and the number of years you have served on that committee or board.

1. Have you ever been convicted of a felony? (A felony is defined as any violation of law punishable by imprisonment longer than one year).

• Yes – Please explain on the attached continuation sheet.

• No

2. Are you a US citizen?

• Yes

• No

If no, do you have permanent residency status?

• Yes

• No

3. Have you been a party to a civil or criminal action involving a financial institution or service provider?

• Yes – Please explain on the attached continuation sheet.

• No

4. Are you now or have you in the last year been subject to the registration and reporting requirements of the Lobbying Disclosure Act (2 U.S.C. 1605)?

• Yes – Please explain on the attached continuation sheet.

• No

5. Are you currently engaged in any business before the CFPB?

• Yes – Please explain on the attached continuation sheet.

• No

_{FINANCIAL DISCLOSURE}

_{Part I: Assets and Income}

_{Please list the following types of Assets and Income in the boxes provided below for yourself, your spouse and any dependent children.}

Assets held for investment with a value greater than $1,000 as of the date you sign this form OR assets held for investment that produced more than $200 in income during the 12-month period prior to the date you sign this form. Such assets include:

• Stocks, bonds, annuities, trust holdings, partnership interests, life insurance, investment real estate, or a privately-held trade or business

• Sector mutual funds: those funds invested in a particular industry, business, or location such as ABC Electronics Fund or XYZ Canada Fund (report the full name of the fund, not just the general family fund name)

• Holdings of retirement plans, such as 401(k)s or IRAs

  • (list each holding except diversified mutual funds)

• Holdings of investment life insurance

• ^{Holdings of variable annuities}

• ^{Defined benefit pension plans provided by a former} employer (include the name of the employer)

You may distinguish any entry for a family member by preceding it with S for spouse, DC for dependent child, or J for jointly held.

Definitions

Diversified Mutual Fund – A mutual fund that does not have a stated policy of concentrating its

investments in one industry, business, or single country other than the United States.

Sector Mutual Fund – A mutual fund that concentrates its investments in an industry, business,

single country other than the United States, or bonds of a single state within the United States.

Dependent Child – A son, daughter, stepson or stepdaughter who is either unmarried and under

age 21 and living in the filer’s house, or considered dependent under the U.S. tax code.

Specific stock,bond, sector mutual fund, type/location of real estate, etc. (Indicate the full name of each specific asset or investment. You may add the ticker symbol to the full name.)

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_{Part II: Affiliations and Representations}

Please list all relationships outside your current employer, in which you represent the interests of a party, or you or your affiliates receive from a party a fee, income, or any other benefit.

Name of Entity; Nature of Relationship or Affiliation (Include brief description.)

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_{Part III: Liabilities}

_{Please list the following types of Liabilities in the boxes provided below for yourself, your spouse and any dependent children}

• A liability over $10,000 owed at any time during the reporting period, other than a loan from a financial institution or business entity granted on terms made available to the general public

• A loan over $10,000 from an individual, such as a friend or a business associate

Do not include:

• Any liability, such as a mortgage, a student loan, or a credit card account, from a financial institution or business entity granted on terms made available to the general public

• Loans secured by automobiles, household furniture, or appliances, unless the loan exceeds the purchase price of the item it secures

• Liabilities that you owe to your spouse or to the parent, sibling, or child of you, your spouse, or your dependent child

_Liabilities

Name of creditor (include city and state where creditor is located)	Type of liability (personal loan, margin account, etc.)
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_{Part IV: Positions You Hold With Boards, Advisory Councils, and Other Similar Groups}

Please list all positions currently hold or held at any time during the past two years, whether or not you were compensated and whether or not you currently hold that position. Positions include an officer, director, employee, trustee, general partner, proprietor, representative, executor, member, or consultant of any of the following:

• Corporation, partnership, trust, or other business entity

• ^{Non-profit or volunteer organization}

• ^{Educational institution}

• ^{Any government or industry advisory board or council}

Do not list any position with a

• ^{Religious entity}

• ^{Social entity}

• ^{Fraternal entity}

• ^{Political entity}

• Any position held by your spouse or dependent child

Positions You Hold or Have Held

Organization (include city and state where organization is located)	Type of organization	Position
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Privacy Act Notice

The information that you provide will be used by the Consumer Financial Protection Bureau (CFPB) to determine qualifications, suitability and availability for service on advisory boards, bodies, panels, committees or other similar groups. The information will be used to conduct background clearances and/or for annual reports on advisory boards, bodies, panels, committees or other similar groups. The information will be used by and disclosed to employees, contractors, agents, and others authorized by the CFPB to receive this information to assist in related activities. The information may also be disclosed to:

1. Appropriate agencies, entities, and persons when: (a) the CFPB suspects or has confirmed that the security or confidentiality of information in the system of records has been compromised; (b) the CFPB has determined that, as a result of the suspected or confirmed compromise, there is a risk of harm to economic or property interests, identity theft or fraud, or harm to the security or integrity of this system or other systems or programs (whether maintained by the CFPB or another agency or entity) that rely upon the compromised information; and (c) the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with the CFPB’s efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm;

2. Another federal or state agency to (a) permit a decision as to access, amendment or correction of records to be made in consultation with or by that agency, or (b) verify the identity of an individual or the accuracy of information submitted by an individual who has requested access to or amendment or correction of records;

3. To the Office of the President in response to an inquiry from that office made at the request of the subject of a record or a third party on that person’s behalf;

4. Congressional offices in response to an inquiry made at the request of the individual to whom the record pertains;

5. Contractors, agents, or other authorized individuals performing work on a contract, service, cooperative agreement, job, or other activity on behalf of the CFPB or Federal Government and who have a need to access the information in the performance of their duties or activities;

6. The U.S. Department of Justice (“DOJ”) for its use in providing legal advice to the CFPB or in representing the CFPB in a proceeding before a court, adjudicative body, or other administrative body before which the CFPB is authorized to appear, where the use of such information by the DOJ is deemed by the CFPB to be relevant and necessary to the litigation, and such proceeding names as a party or interests:

(a) The CFPB;

(b) Any employee of the CFPB in his or her official capacity;

(c) Any employee of the CFPB in his or her individual capacity where DOJ has agreed to represent the employee; or

(d) The United States, where the CFPB determines that litigation is likely to affect the CFPB or any of its components;

7. A court, magistrate, or administrative tribunal in the course of an administrative proceeding or judicial proceeding, including disclosures to opposing counsel or witnesses (including expert witnesses) in the course of discovery or other pre-hearing exchanges of information, litigation, or settlement negotiations, where relevant or potentially relevant to a proceeding, or in connection with criminal law proceedings; and

8. To the public in the form of names, affiliations, and other pertinent biographical information of board or committee members.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this collection is 3170-XXXX. It expires on XX/XX/XXXX. The time required to complete this information collection is estimated to average approximately 60 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.

The Consumer Financial Protection Bureau (CFPB) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, political beliefs, sexual orientation, marital or family status, parental status or protected genetic information. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means of communication of program information (Braille, large print, audiotape, etc.) should contact Liza Strong, Labor and Employee Relations, Office of Human Capital.  To file a complaint of discrimination, contact the Treasury Department at 202-622-9252. CFPB is an equal opportunity provider and employer.

The collection of this information is authorized by Pub. L. No. 111-203, Title X, sections 1011, 1012, 1014, codified at 12 U.S.C. §§ 5491, 5492, 5494. You are not required to provide any identifying information, but not doing so may result in non-selection of a prospective advisory board, body, panel, committee or other similar group membership.

I certify that the statements I have made on this form and all attached statements are true, complete, and correct to the best of my knowledge.

_{Signature Date (mm/dd/yy)}

Continuation Sheet to Form

If you need more space for an answer, use this sheet. Please number each answer to correspond to the number on this form. When you have completed your answers, attach to this form.

Name (Last, First, Middle) __________________________________________________________

Social Security Number __________________________________________________________

APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP 10

Consumer Financial Protection Bureau