1583 Notice or Application for Capital Distribution

OMB No. 1550-0059
Expiration Date: 2/29/2004

Docket Number:

OFFICE OF THRIFT SUPERVISION
NOTICE OR APPLICATION FOR CAPITAL DISTRIBUTION
PAPERWORK REDUCTION ACT STATEMENT
The Office of Thrift Supervision (OTS) will use this form to acquire information concerning the amount
of capital that an institution intends to distribute, pursuant to 12 C.F.R. § 563 Subpart E of the OTS
regulations.
Public reporting burden for this collection of information is estimated to average 16.5 minutes per
response, including the time for reviewing instructions and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of the collection of
information, including suggestions for reducing this burden, to the Office of Thrift Supervision, Office of
Examination Policy, 1700 G Street, N.W., Washington, D.C. 2052; and to the Office of Management and
Budget, Paperwork Reduction Project (1550-0059), Washington, D.C. 20503.

OTS Form 1583
Revised April 2001

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OMB No. 1550-0059
Expiration Date: 2/29/2004

Docket Number:

OFFICE OF THRIFT SUPERVISION
NOTICE OR APPLICATION FOR CAPITAL DISTRIBUTION
TO: Office of Thrift Supervision Date of Filing:

We, the undersigned executive officer and secretary, pursuant to the resolution of majority of the
members of the board directors, of:
Savings Institution Name
Street Address of Savings Institution (include City, State and Zip Code)
(hereinafter the Institution), hereby provide _____notice/____application (select one) to the Office of
Thrift Supervision (OTS) that the Institution intends to issue a capital distribution in the amount of
$ ________, pursuant to 12 C.F.R. Section 563.140, and do hereby certify:
1. That to the best of our belief, the institution ____qualifies/____does not qualify (select one) for
expedited treatment, pursuant to 12 C.F.R. Sections 563.143 and 516.25(a);
2. That, if applicable, the Institution has attached any additional information required, pursuant to 12
C.F.R. Section 563.146; and
3. That we are aware that the OTS may request additional information or may impose conditions for
the distribution of capital and may determine that such distribution does not comply with the
requirements of 12 C.F.R. Section 563.143.
__________________________________
Executive Officer

________________________________
Secretary
___________________________________
Date of Receipt by OTS

OTS Form 1583
Revised April 2001

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