Markup of Interagency Biographical and Financial Report (3064-0006) - 04-28-2017

OMB No. for FDIC 3064-0006
OMB No. for FRB 7100-0134
OMB No. for OCC 1557-0014
OMB Nos. for OTS 1550-0005, -0015, -0047
Expiration Date: 04/30/2017

INTERAGENCY BIOGRAPHICAL AND FINANCIAL REPORT
Public reporting burden for this collection of information is estimated to average two hours for biographical information
and two hours for financial information. This estimate includes time to gather and maintain data in the required form, to
review instructions, and to complete the information collection. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden to: Paperwork Reduction
Act, Legal Division, Federal Deposit Insurance Corporation, 550 17th Street, NW, Washington, DC 20429; Secretary,
Board of Governors of the Federal Reserve System, 20th and C Streets, NW, Washington, DC 20551; or Licensing
Activities Division, Comptroller of the Currency, 250 E Street, S.W., Washington, DC 20219; or Office of Supervision
Policy, Office of Thrift Supervision, 1700 G Street, N.W., Washington, DC 20552; and to the Office of Management
and Budget, Paperwork Reduction Project, Washington, DC 20503.
An organization or a person is not required to respond to a collection of information unless it displays a currently valid
OMB control number.

GENERAL INFORMATION AND INSTRUCTIONS
This Interagency Biographical and Financial Report (report) is used by individuals 1 in
conjunction with other corporate filings to the appropriate regulatory agency. This report is not a
stand-alone document.
Preparation
Use of this report format is not mandatory. If an alternative format is used, it must provide all
requested information, including the certification. All questions must be answered with complete
and accurate information that is subject to verification. If the answer is “none,” “not applicable,”
or “unknown,” so state. Answers of “unknown” or “yes” should be explained.
The questions are not intended to limit the presentation nor are the questions intended to
duplicate information supplied on another form or in an exhibit. For example, a cross-reference
to the information is acceptable. Any cross-reference must be made to a specific cite or location
in the documents, so the information can be located easily. Use additional sheets as necessary.
Each regulatory agency will provide additional instructions for use and preparation. If the report
is not complete, the regulatory agency may either request additional information or return the
filing. If you are a foreign national or a United States citizen who currently resides in a foreign
country, additional information may be necessary.
Financial statements from individuals must have “as of” dates of not more than 90 days prior to
the date the financial report is submitted. All amounts in this report must be based on current
1

A company seeking to acquire direct or indirect control of a bank or savings associationthrift should consult with
the appropriate regulatory agency for filing instructions.
i

market value in United States dollars 2 and agree with any totals in the supplementary schedules.
In addition to the sample financial schedules, you may wish to provide supplementary schedules
for other items on the financial statement. If the sample financial statement is used, an answer is
required to each item. If you submit an alternative Financial Report format, the information must
respond to each request for information contained in the sample Financial Report.
In addition, each regulatory agency specifically reserves the right to require up to five years of
financial data from any acquiring person as well as the filing of additional information and/or
statements, such as a federal income tax return or a current appraisal to support an asset's value.
If you have been convicted of any criminal offense involving dishonesty, breach of trust, or
money laundering, or have agreed to enter into a pretrial diversion or similar program in
connection with a prosecution of such offense (12 U.S.C. § 1829), you must obtain approval
from the FDIC before you can own, control, participate in the affairs of, or become an institutionaffiliated party of a depository institution.
Each individual must report promptly any material change in the biographical report or financial
condition that occurs during the review period for the filing. For additional information
regarding the processing procedures and guidelines and any supplemental information that may
be required, refer to the appropriate regulatory agency's procedural guidelines (that is, the
Comptroller's Licensing Manual, the FDIC's Rules and Regulations (12 C.F.R. Part 303), or the
OTS' Application Processing Handbook), contact the agency directly for specific instruction, or
visit its Web site at www.occ.treas.gov, www.fdic.gov, www.ots.treas.gov, or
www.federalreserve.gov.
Definitions
For purposes of this document:
Affiliate means any company that owns or controls, is owned or controlled by, or is under
common ownership or control with a depository institution or depository institution holding
company.
Associated means associated as an officer, director, organizer, partner, trustee, or principal
shareholder or owner.
Company means any corporation, association, partnership, limited liability company, business
trust, sole proprietorship, joint venture, or other similar organization.
Depository institution means any bank (including a national, state, district, or foreign bank),
savings association, savings bank, savings and loan association, building and loan association,
homestead association, cooperative bank, trust company, industrial bank or loan company, or
2

Provide the foreign currency exchange rate and conversion date, if applicable.
ii

Formatted: Font: Not Italic

credit union. A United States office, including a branch or agency, of a foreign bank is a
depository institution.
Management official includes a senior executive officer; director; advisory or honorary director of a
depository institution with total assets of $100 million or more; branch manager; trustee of a
depository organization under the control of trustees; and any person who has a representative or
nominee serving in any of those capacities.
Principal shareholder or owner means a person who directly or indirectly owns, controls, or
holds (either individually or as a member of a group) the power to vote 10 percent or more of any
class of voting securities or other voting equity interest of the entity.
Confidentiality
Any individual desiring confidential treatment of specific portions of the report must submit a
request in writing with the report. The request must discuss the justification for the requested
treatment. The individual's reasons for requesting confidentiality should specifically demonstrate
the harm (for example, loss of competitive position, invasion of privacy) that would result from
public release of information (5 U.S.C. section 552). Information for which confidential
treatment is requested should be: (1) specifically identified in the public portion of the report (by
reference to the confidential section); (2) separately bound; and (3) labeled “Confidential.” The
individual should follow the same procedure for a request for confidential treatment for the
subsequent filing of supplemental information to the report.
The individual should contact the appropriate regulatory agency for specific instructions
regarding requests for confidential treatment. The agency will determine whether the
information will be treated as confidential and will advise the individual of any decision to make
available to the public information labeled “Confidential.”

iii

INTERAGENCY BIOGRAPHICAL AND FINANCIAL REPORT
This is filed with respect to:
Name of Subject Institution or Holding Company, Location
Type of Filing

Position

Bank or Thrift Charter
Bank or Thrift Holding Company
Change in Bank Control
Change in Senior Executive Officer or Director
Citizenship Waiver
Charter Conversion
Deposit Insurance
Federal Branch or Agency
Other

Organizer
Director
Senior Executive Officer
Title:
Principal Shareholder
Trustee
Manager
Manager
Other

BIOGRAPHICAL REPORT
1. Personal Information
(a) Name
Last

First

(Middle-no initials)

(b) Residence
(Street Address)
(City)

(State)

(ZIP Code)

(Country)

(c) If at residence less than five years, list addresses and dates occupied for past five years.
Date From

Date To

(d) Date of Birth:

Number and Street

Month:

State

ZIP Code

Day:

Country

Year:

(e) Place of Birth:
(City)

(State)

(f) United States Social Security Number:
(g) Citizenship
Country

(Date, if Naturalized)

1

(Country)

(h) If not a United States citizen, provide:
Passport Number:
Home Country Identification Number:
Immigration File Number:
Father's full name
Mother's full name, including maiden name
(i) Telephone and fax numbers where you may be reached during business hours and an email address:

(Area Code, Telephone Number, including Country Code if outside U.S.)

(Fax Number)

E-mail Address

(j) List other names you used and the period of time you used them (for example, your
maiden name, name by a former marriage, former name, alias, or nickname). If the other
name is your maiden name, put “nee” in front of it.

2. Employment Record
(a) List employment in reverse chronological order for the last five years. The list should
include the beginning and ending dates of employment, the employer’s name and location
(city, state), nature of business, title or position, nature of duties, and reason for leaving.

(b) Have you ever been dismissed or asked to resign from any past employment, including a
less than honorable discharge from military service?
Yes
No
If “yes,” provide the employer’s name, address, and telephone number; title or position;
date of discharge; and explanation.

2

3. Education and Professional Credentials
(a) List each diploma or degree from high schools, colleges, universities, or other schools.
School's Name/Location

From

To

Degree

(b) List each professional license or similar certificate you now hold or have held (for
example, Attorney, Physician, CPA, NASD or SEC registration).
License

Issuing Authority

Date Issued

Status

Expiration

4. Business and Banking Affiliations
(a) List any company with which you are associated, providing the company name, location,
nature or type of business, position held or relationship to the company, ownership
percentage, and beginning date of the relationship.

(b) List the name of any depository institution or depository institution holding company with
which you are or were associated. Also list the location, nature of banking activity,
position held or relationship, ownership percentage, and beginning and ending dates of
the relationship.

3

(c) Are you in the process of being considered for a senior executive officer or director
position at another depository institution or depository institution holding company?
Yes
No
If “yes,” provide the name of the depository institution or depository institution holding
company and the position. If the application has been submitted for regulatory review,
provide the name of the regulatory agency.

(d) Are you now or are you proposed to be a “management official” of another insured
Yes
No
depository institution or depository institution holding company?
If “yes,” explain either why the potential interlock is not a violation of the Depository
Institution Management Interlocks Act (12 U.S.C. §§ 3201-3208) or what action will be
taken to prevent a violation.

5. Legal and Related Matters
(a) Have you been involved in any of the following filings where the filing was denied,
disapproved, withdrawn, or otherwise returned without favorable action by a federal or
state regulatory authority or a self-regulatory organization:
(1)

Acharter or license application, a depository institution holding company
application, or a federal deposit insurance application, in which you were listed as
an organizer, director, senior executive officer, or a person that would own or
control (either individually or as a member of a group) 10 percent or more of any
class of voting securities or other voting equity interest of the institution, or
Yes
No
similar position?

(2)

A merger application in which you were listed as a director, senior executive
officer, or similar position?
Yes
No

4

(3)

A notice of change in director or senior executive officer, or similar form, in
which you were listed as a director, senior executive officer, or similar position?
Yes
No

(4)

A notice of change in control for a depository institution or other company, or a
similar form, in which you were listed (either individually or as a member of a
group) as an acquirer or transferee?
Yes
No

(5)

Any other application, notice, or other regulatory or administrative request which
was filed with a federal or state regulatory authority or a self-regulatory
Yes
No
organization in which you were listed in some capacity?

(b) Have you or any depository institution or depository institution holding company with
which you are or were associated been subject to any supervisory agreement, enforcement
action, civil money penalty, prohibition or removal order, or other supervisory or
administrative action taken or imposed by any federal or state regulatory authority or
Yes
No
other governmental entity?
(c) Has any depository institution with which you are or were associated:
(1)

Been placed into conservatorship or receivership or otherwise failed?
Yes

No

(2)

Received financial assistance from a federal agency or instrumentality (for
example, FDIC, Resolution Trust Corporation, Federal Savings and Loan
Insurance Corporation)?
Yes
No

(3)

Merged with or been acquired by an institution that received financial assistance
from a federal agency or instrumentality in connection with the transaction?
Yes
No

(d) Have you or any company with which you are or were associated:
(1)

Filed a petition under any chapter of the Bankruptcy Code or had an involuntary
Yes
No
bankruptcy petition filed against you or the company?

(2)

Defaulted on a loan or financial obligation of any sort, whether as obligor,
cosigner, or guarantor?
Yes
No

(3)

Forfeited property in full or partial satisfaction of any financial obligation?
Yes
No

5

(4)

Had a lien placed against property for failure to pay taxes or other debts?
Yes
No

(5)

Had wages or income garnished for any reason?

Yes

No

(6)

Failed or refused to pay any outstanding judgments?

Yes

No

(e) Have you or any company or depository institution with which you are or were associated
been involved in any lawsuit, formal or informal investigation, examination, or
administrative proceeding that may result in, or resulted in, any penalty (including, but
not limited to, any sanction, fine, order to pay damages, loss of right or benefit, forfeiture
of property interest, or revocation of license), agreement, undertaking, consent, judgment,
or order imposed by or entered into with any of the following entities:
(1)

Any federal or state court?

Yes

(2)

Any department, agency, or commission of the United States government?
Yes
No

(3)

Any state, municipal, or foreign governmental entity?

Yes

No

No

(4)

Any self-regulatory organization (for example, NASD, FASB, state bar)?
Yes
No
(f) Have you or any company or depository institution with which you are or were associated
been arrested for, charged with, indicted for, or convicted of (including a conviction
where the record was expunged), or ever pleaded nolo contendere to, any criminal matter
(other than minor traffic violations)?
Yes
No
(g) If you answer “yes” to any question in 5(a) through 5(f), provide your explanation by
identifying the number of the question, describing the situation in detail, and, where
relevant, including the:
•
•
•
•
•

•
•
•
•

Name and location of any institution, company, party, court, regulatory agency, or
self-regulatory organization involved.
Nature of your association with any institution or company (for example, officer,
director, organizer, principal shareholder, or owner).
Type of any application, notice, or other regulatory or administrative request.
Nature of any supervisory, enforcement, or administrative action.
Direct and indirect debt terms, defaulted amount, and creditor regarding any financial
obligation.
Date of any relevant event.
Nature of any lawsuit, charge, or proceeding.
Jurisdiction in which any legal proceeding occurred.
Resolution or disposition of the matter.

6

6. Additional Information
Present any other information you believe is important to evaluate your filing. If you are
involved in the organization of a new depository institution or depository institution holding
company, discuss your specific role.

7

FINANCIAL REPORT

FINANCIAL STATEMENT AS OF

ASSETS
Cash on hand and in
depository institutions

, ______

LIABILITIES AND NET
WORTH
$

Accounts payable

Marketable securities
(Schedule A)

Notes payable and other
loans (Schedule F)

Notes receivable
(Schedule B)

Real estate mortgages
(Schedule C)

Real estate
(Schedule C)

Other liabilities (Schedule G)

Proprietary interests and
other securities
(Schedule D)

$

TOTAL LIABILITIES
Net worth (Total assets less
total liabilities)

Retirement funds and other
assets (Schedule E)

TOTAL ASSETS

TOTAL LIABILITIES AND
NET WORTH

$

8

$

CONTINGENT LIABILITIES
In addition to the liabilities listed on the Financial Statement, have you endorsed, guaranteed, or become
otherwise indirectly or contingently liable for the debts of others or through a pending lawsuit?
Yes

No

If “yes,” complete the following:

Name and Address of
Debtor or Obligor

Name and Address of
Creditor or Obligee

Description and Value of Collateral

TOTAL

Date
Due

Current
Amount

$

9

SUPPORTING SCHEDULES

Schedules must agree in total with the appropriate item contained in the Financial Statement on page 8
of this report.
Schedule A ─ Marketable Securities
Indicate all debt and equity securities listed on an exchange or otherwise regularly traded in an open market. Separate debt and
equity securities. Securities of closely held corporations should be listed on Schedule D—Proprietary Interests. The
description should include the name of the issuer, the principal amount or number of shares held, and the interest rate, if
applicable. Small holdings may be aggregated and shown as “other” provided that they account for no more than 10 percent of
marketable securities.

Description

Market Value
$

TOTAL

$

Schedule B ─ Notes Receivable
The description should include the name of the obligor, the note's maturity and terms of repayment, and a description of any
collateral. If the note is payable to you and others jointly, indicate only your beneficial interest under Current Balance.
Current
Balance

Description
$

TOTAL

$

10

Schedule C ─ Real Estate and Related Loans
List all real estate in which you hold a beneficial interest. Submit year-end financial statements, including profit and loss statements,
for the last two years for each investment (exclude residence) in which you have an interest equal to 10 percent or more of your net
worth. Also submit a cash flow statement on any investment property valued at 10 percent or more of net worth.

Description and
Location
(City and State)

Owner of
Property

Percent
Ownership

Mortgage
Holder

Maturity
Date

TOTAL

Current
Market
Value*

Current
Balance**

$

$

$

$

* Carry TOTAL forward to Assets - Real estate
** Carry TOTAL forward to Liabilities - Real estate mortgages

Schedule D ─ Proprietary Interests and Other Securities
List all companies, the shares of which are not listed on a securities exchange or otherwise regularly traded, in which you hold a
beneficial interest. (Submit year-end financial statements, including profit and loss and cash flow statements, for the last two years
for each business interest in which you have an interest equal to 10 percent or more of your net worth.)

Name and Address
of Company

Legal Form
of Company

Nature of Business

Percent
Ownership

Current Value
$

TOTAL

$

11

Schedule E - Other Assets
Include retirement funds (for example, 401K, IRA, Keogh), accounts receivable, merchandise and inventory at lower of cost or
market value, machinery and equipment (less depreciation), and life insurance at its cash surrender value.

Description

Basis for Valuation

Current Value
$

TOTAL

$

12

Schedule F ─ Notes Payable and Other Loans
Indicate all loans or notes payable, including loans on life insurance and retirement funds (but not real estate mortgages listed in
Schedule C). Loan origination information must include the original date, loan amount, and co-makers, if any, and their percent
obligation. Small obligations may be aggregated and shown as “other,” provided that they account for no more than 20 percent of
other loans and notes payable. Indicate any debt that is contractually delinquent by an asterisk next to the current balance.

Name and Address of Creditor
and Loan Origination Information

Description and Value of
Collateral

Maturity Date

Current
Balance
$

TOTAL

$

Schedule G - Other Liabilities
Include interest and taxes due and unpaid, other debts accrued, and other liabilities.

Payable To

Description

Maturity Date

Current Balance
$

TOTAL

$

13

Cash Flow Statement*

Sources of Cash

20

20

Projected Current
Year 20

Projected Next
Year 20

Salaries, wages, commissions,
and other employment income
$

$

$

$

$

$

$

$

Rents, royalties, and
investments
Income from dividends and
interest
Income and other distributions
from partnerships

Other sources**

Total cash received
Uses of Cash
Personal living expenses
(rent, household)
Fixed obligations***
Income taxes
Capital contributions to
partnerships
Other uses**
Total cash outlay

NET CASH FLOW (deficit)

* Discuss any significant changes on a separate page.
** Itemize on a separate page any items amounting to 10 percent or more of total cash received or total cash outlay.
*** Fixed obligations include debt service on all loans and any budgeted capital improvement expenditures for real
estate investments. Any loan proceeds or debt service related to this transaction should be included in
projections for other sources or uses.

14

Privacy Act Notice
The solicitation and collection of this information, including a Social Security Number, is authorized by those
statutes that require an appropriate federal banking agency to determine the competence, experience, integrity, and
financial ability of individuals proposing to serve a federally regulated financial institution in an official capacity –
that is, as a director, officer, employee, or principal shareholder. These statutes include: 12 U.S.C. § 27 (national
bank charters); 12 U.S.C. § 1464 (federal savings bank charters); 12 U.S.C. § 1815 (federal deposit insurance); 12
U.S.C. § 1817(j) (changes in control of insured depository institutions); and 12 U.S.C. § 1831(i) (agency disapproval
of directors and senior executive officers of insured depository institutions or depository institution holding
companies). The provision of requested information, including a Social Security Number, is voluntary. However,
the failure to provide any requested information may result in denial, disapproval, or delay in the processing of an
application or notice.
Depending on the manner in which an appropriate federal banking agency maintains solicited information, some or
all of that information may be subject to the Privacy Act of 1974, 5 U.S.C. § 552a. In such instances, disclosures of
covered information may be made to: (1) third parties to complete background checks; (2) financial institutions for
supervisory purposes; (3) governmental, tribal, self-regulatory, or professional organizations when information is
relevant to either a known or suspected violation of law or licensing standard or relevant and necessary to the
governmental or self-regulatory organization’s regulation or supervision of financial service providers; (4) the
Department of Justice, a court, an adjudicative body, a party in litigation, or a witness when relevant and necessary
to a legal or administrative proceeding; (5) congressional offices when the information is relevant to an inquiry
initiated on behalf of its provider; (6) an agency’s contractors or agents; and (7) other third parties when mandated or
authorized by statute.
Additionally, while certain of the solicited information is exempt from disclosure under the Freedom of Information
Act because disclosure would constitute a clearly unwarranted invasion of personal privacy, other information is not
exempt. Nonexempt information will ordinarily include the names of individuals, the financial institutions that they
propose to serve, the statutory context in which information has been provided, and prior bank-related employment
and affiliation.

CERTIFICATION
*If a joint financial statement is being submitted, both parties should complete the “Certification.”

I understand that the appropriate regulatory agency may conduct extensive checks into my
background, experience, and related matters in conjunction with my application or filing.
I certify that the information contained in the biographical report and financial report, including
all attachments, has been carefully examined by me and is true, correct, and complete. I
acknowledge that any misrepresentation or omission of a material fact constitutes fraud in the
inducement and may subject me to legal sanctions provided by 18 U.S.C. §§ 1001 and 1007.
Signed this

day of

,

.

Signature

Signature*

Print or type name

Print or Type name

Title (if applicable)

Title (if applicable)

15