Form 3170-XXXX Certification Regarding Financial Interests (Academic Re

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

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Date

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Name (Print)

I am unable to certify to the above.
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Signature

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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
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existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information.