3170-XXXX Entity-specific Certification

OMB#3170-XXXX

1700 G Street NW, Washington, DC 20552

CERTIFICATION FOR ENTITY-SPECIFIC PROJECTS

Academic Research Council

Project Name: (to be filled in by CFPB)

Brief Project Description: (to be filled in by CFPB)

Specific Entities Involved: (to be filled in by CPPB)

Certification

I certify that I do not have any financial interest in [relevant entity name(s), to be filled in by CFPB] or other financial interests that could influence my work or advice on this project. If this changes, I will notify the CFPB before continuing to work on the project.

______________________________________________ ______________________

Signature Date

______________________________________________

Name (Print)

I am unable to certify to the above.

______________________________________________ ______________________

Signature Date

______________________________________________

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 five 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.