Form OH Modernization S OH Modernization S OH QLT Survey



Federal Deposit Insurance Corporation	Chicago Regional Office
Division of Risk Management Supervision	Phone (312) 382-7500
300 South Riverside Plaza, Suite 1700, Chicago, IL 60606	Fax (312) 382-6901



OMB Number: 3064-0127

Expiration Date: June 30, 2020

BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to, the Paperwork Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17^th St. NW, Washington, DC 20429; and to the Office of Management and Budget, Paperwork Reduction Project (3064-0127), Washington, DC 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection unless it displays a current valid OMB control number.

INSTRUCTIONS: Please fill out the following information and select one of the two options in the survey below.

Institution Name: ______________________________________________________

Address: ______________________________________________________

______________________________________________________

Current Charter Type: ______________________________________________________

• The institution referenced above will, by operation of Ohio law, become an Ohio-chartered state bank effective January 1, 2018.

• The institution referenced above elects to operate as a savings and loan association, effective January 1, 2018, by filing a written notice of such election with the Ohio Superintendent of Financial Institutions.

Name of Signing Official: ______________________________________________________

Office/Title of Signing Official: ______________________________________________________

Signature: ______________________________________________________

Date: ______________________________________________________