NCUA 4012 Report of Official and Agreement to Serve

REPORT OF OFFICIAL AND AGREEMENT TO SERVE
TO: NATIONAL CREDIT UNION ADMINISTRATION

Federal Credit Union

Proposed
Title of Prospective Position:
Name: Mrs.
Maiden Name: (If Different From Above)
Address (Res.): Street:
City:
State:
Zip Code:
Telephone Number:
Place of Birth:
Date of Birth:
Employer:
Social Security Number (Optional):
Type of Business:
Number of years with present employer:
Your position title:

Education background (enter highest grade completed)
High School:
College:
Major Field of Study:

Other training or experience:

Are you willing to accept the position of trust for which you have been
selected and to remain in office until a qualified successor is found?

Yes

No

Have you been informed as to the general duties and responsibilities
of an official of the proposed Federal Credit Union and are you willing
to devote the time necessary to familiarize yourself with and to
perform your duties?

Yes

No

Yes

No

Estimated number of hours per month you will be able to volunteer:
IF THE ANSER IS YES TO THE FOLLOWING QUESTION, PLEASE
PROVIDE INFORMATION AS INSTRUCTED ON THE FOLLOWING PAGE:
Have you ever been convicted of any CRIMINAL OFFENSE
involving dishonesty or a breach of trust?

To facilitate the process of obtaining a credit and background check, please provide the following:
1. Any other names which you have used:
2. Previous address (if your address changed over the past 2 years):
3. Name of Spouse:

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READ THE FOLLOWING CAREFULLY BEFORE SIGNING
CERTIFICATION AND AGREEMENT TO SERVE
I certify that the information provided on this form is true and correct. Further, I,
the undersigned, having been duly designated to occupy the position(s) indicated
above, do hereby agree to serve in the above-stated office(s) of this proposed
credit union until the first annual meeting held in accordance with the Federal
Credit Union Act and the bylaws of this credit union and until the election of my
successor(s). I further pledge to carry out the duties and responsibilities
commensurate with said office(s) as promulgated by the Federal Credit Union Act
and the bylaws of this credit union. I have read the Privacy Act Notice that
follows.
Date

Signature

NCUA 4012

Witness

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PRIVACY ACT NOTICE
The Privacy Act of 1974 (Public Law 93-579) requires that you be advised as to
the legal authority, purpose and uses of the information solicited by this form.
Pursuant to Sections 104 and 205(d) of the Federal Credit Union Act, the
information in this form is requested for the purpose of completing the
investigation required for a new Federal credit union. The information in this form
will be primarily used in considering the soundness of the management for the
proposed Federal credit union. However, this form may be disclosed to any of the
following sources: a congressional office in response to your inquiry to that
office; an appropriate Federal, state or local authority in the investigation or
enforcement of a statute or regulation; or employees of a Federal agency for audit
purposes. Failure to complete this form or omission of any item of information,
except for disclosure of your social security number, may result in a delay in the
process for chartering the proposed Federal credit union. In accordance with
Section 792.68 of NCUA's regulations, you are not required to furnish your social
security number on this form. Your social security number, if voluntarily
provided, will be used to more easily verify the information required by this form.
No penalty will result to you as a management official or to the chartering of the
proposed Federal credit union if you do not provide your social security number.
Further information needed if answer to CRIMINAL OFFENSE question on the
previous page was YES:

CRIMINAL OFFENSE:
Nature of offense:
Date of occurrence:
Date of conviction:
Sentence conferred:
(Attach a separate sheet if space provided is not adequate)

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CRIMINAL OFFENSE GUIDELINES
The Federal Credit Union Act, Subchapter II, Section 205(d), requires that, except
with the written consent of the NCUA Board, no person shall serve as director,
officer, committee member, or employee of an insured credit union who has been
convicted or who is hereafter convicted, of any criminal offense involving
dishonesty or breach of trust. To assist the NCUA Board in making a
determination of the fitness of a person who is selected to serve and who the
organizer believes is qualified to serve as an official, the specific information
above will need to be furnished.
If the NCUA Board believes that, in view of the facts presented and the date of the
offense, they can give their consent to the appointment they will so advise that
person in writing. If on the other hand, the NCUA Board believes after careful
consideration that they cannot in good conscience give their written consent to
the appointment they will contact the organizer and ask that another person be
selected for the position. The person selected will have to complete a Report of
Official and Agreement to Serve.
An indication of whether the bonding company would agree to provide coverage
should be included if the person is to serve as treasurer. Bonding company
agrees to provide coverage: YES
NO

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AUTHORIZATION TO OBTAIN A CREDIT REPORT
The National Credit Union Administration (NCUA) may evaluate the competence,
experience, character, and integrity of any individual who is to serve as an
official, employee, or committee member of a federally insured credit union, in
accordance with §1790a of the Federal Credit Union Act and Chapter 1, §V.B.4 of
the NCUA Chartering and Field of Membership Manual.
NCUA may disapprove any individual whose employment it believes will not be in
the best interest of the credit union or of the public. To assist in the evaluation
process, NCUA may obtain and review an individual’s credit report.
Your signature on this document authorizes NCUA to obtain a copy of your credit
report.
Last
First
Middle
Social Security Number:
Date of Birth:

Signature

Date

NCUA 4012

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