Form 1583 Notice of Proposed Declaration of Dividend

OMB No. 7100-0339
Expiration Date: 08/30/2016

Docket Number:

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, Corporate & International Activities, 1700 G Street, N.W., Washington, D.C.
20552; and to the Office of Management and Budget, Paperwork Reduction Project (7100-0339),
Washington, D.C. 20503.

Page 1 of 2
Form 1583
Revised November 2008

OMB No. 7100-0339
Expiration Date: 08/30/2016

Docket Number:

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 to
$
, 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

Page 2 of 2
Form 1583
Revised November 2008