Form 3170-XXXX Global Certification

OMB#3170-XXXX

1700 G Street NW, Washington, DC 20552

CERTIFICATION REGARDING FINANCIAL INTERESTS

Academic Research Council

I certify that the CFPB has given me an overview of the kind of work I am likely to perform as a member of the Academic Research Council (ARC). I further certify that, for issues about which I anticipate giving advice as a member of the ARC, I do not have any financial interests that could influence my advice, or create an appearance that my advice could be so influenced. If this changes, I will recuse myself from providing advice on issues relating to my financial interests unless the CFPB gives its approval for me to take part.

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Signature Date

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Name (Print)

I am unable to certify to the above.

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Signature Date

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Name (Print)

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 3170-00XX. It expires on XX/XX/XXXX. The time required to complete this information collection is estimated to average approximately ten 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.