3170-XXXX Certification for Entity-Specific Projects (Academic Res

OMB Control #3170-XXXX
Expiration Date: XX/XX/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
in by CFPB]

[relevant entity name(s), to be filled

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
______________________________________________
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
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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
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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
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The Bureau will treat the information collected consistent with its confidentiality regulations at 12 C.F.R. Part
1070, et seq.