Form 3170-XXXX Certification Regarding Financial Interests (Academic Re

1700 G Street NW, Washington, DC 20552

OMB Control #3170-XXXX
Expiration Date: XX/XX/XXXX

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.
______________________________________________
Signature

______________________
Date

______________________________________________
Name (Print)

I am unable to certify to the above.
______________________________________________
Signature
______________________________________________
Name (Print)

______________________
Date

Paperwork Reduction Act
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 OMB
control number for this collection is 3170-XXXX. It expires on MM/DD/YYYY. The time required to complete
this information collection is estimated to average approximately 10 minutes per response, including the time
for reviewing any instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. The obligation to respond to this collection of
information is voluntary. Comments regarding this collection of information, including the estimated response
time, suggestions for improving the usefulness of the information, or suggestions for reducing the burden to
respond to this collection should be submitted to Bureau at the Consumer Financial Protection Bureau
(Attention: PRA Office), 1700 G Street NW, Washington, DC 20552, or by email to [email protected].
The Bureau will treat the information collected consistent with its confidentiality regulations at 12 C.F.R. Part
1070, et seq.