Form 3170-XXXX Application to Serve on Advisory Board

OMB Control #3170-XXXX
Expiration Date: XX/XX/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, or as outlined under the attached Privacy Act
Statement. 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
*Voluntary - See Privacy Act

List your business or professional experience not listed on your resume.

Identify your area of expertise.





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Consumer protection
Financial services
Community development
Fair lending and civil rights
Consumer financial products or services



Depository institution primarily serving underserved
communities



Representing communities that have been significantly
impacted by higher-priced mortgage loans



Other

List education and any specialized experience not listed on your resume.

List other affiliations and/or service as a community leader that would benefit you in your role as a member of the advisory
group.

APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

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

6.

Have you failed to pay any tax, penalty, or interest liability during the current or last three calendar years
within forty-five (45) days of the date of which the IRS gave notice of the amount due and request for
payment?
 Yes – Please explain on the attached continuation sheet.
 No

7.

Have you now or ever been under investigation by the IRS for possible criminal offenses?
 Yes – Please explain on the attached continuation sheet.
 No

APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

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

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
o (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. Asset value is not required.)
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APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

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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 12-month period prior to the date you sign this
form, other than a loan from a financial institution or business entity granted on terms made
available to the general public such as a trading margin account or other loans from financial
institutions offered on terms not 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.)
Exact amount of liability is not required

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APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

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

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
o Religious entity
o Social entity
o Fraternal entity
o Political entity
o 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

Years Held

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APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

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OMB Control #3170-XXXX
Expiration Date: XX/XX/XXXX
Privacy Act Statement
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) To the public in the form of names, affiliations, and other pertinent biographical information of board or committee
members; and
(8) Appropriate agencies, entities, and persons to the extent necessary to obtain information relevant to making a
determination of whether an individual is eligible to serve on a CFPB board or committee.

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. Providing your identifying information is voluntary, but not doing so may result in non-selection of a
prospective advisory board, body, panel, committee, or other similar group membership. However, failure to provide your Social
Security number may not be the reason for non-selection.

APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

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OMB Control #3170-XXXX
Expiration Date: XX/XX/XXXX
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 60 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 not disclose any personally identifiable information collected except to the extent that it is required to do so by law and as
provided in the Privacy Act Statement listed above. Additionally, the Bureau will treat the information collected consistent with its
confidentiality regulations at 12 C.F.R. Part 1070, et seq.

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)

APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

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OMB Control #3170-XXXX
Expiration Date: XX/XX/XXXX
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
Consumer Financial Protection Bureau

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