Form Member Director 1 Member Director 1 Federal Home Loan Bank Member Director Eligibility Certi

FEDERAL HOME LOAN BANK
MEMBER DIRECTOR
ELIGIBILITY CERTIFICATION FORM
1. Print or type your full name:
________________________________________________________________________
2. Are you a citizen of the United States? Yes

No

3. Provide the address of your principal residence:
________________________
Street

_____________________
City

__________
State

_________
Zip code

4. Provide the following information about the institution you serve as an officer or director that
is a member of your Federal Home Loan Bank:
__________________________________
Name of member
________________
Telephone number
________________________
Street

_________________________________
Your title or position

__________________
Fax number

_______________________
E-mail address

____________________
City

__________
State

_________
Zip code

________________________ ____________________
Mailing address (if different) City

__________
State

_________
Zip code

5. Provide the name and location of any other institution you serve as an officer or a director
that is a member of any Federal Home Loan Bank:
______________________
Name of member

________________
City

_________
State

__________________
Your title or position

______________________
Name of member

________________
City

_________
State

__________________
Your title or position

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FEDERAL HOME LOAN BANK MEMBER DIRECTOR ELIGIBILITY CERTIFICATION FORM

6. Does each member listed in LINE 4 and LINE 5 comply with all of its applicable minimum
capital requirements established by its appropriate federal or state regulator?
Yes

No

If you answered No, identify the non-compliant institution and note the Bank of which it is a
member.
__________________________________________
Name of member

___________________________
Bank District

__________________________________________
Name of member

___________________________
Bank District

I HEREBY CERTIFY that the information provided on this Federal Home Loan Bank Member
Director Eligibility Certification Form is true, correct, and complete to the best of my
knowledge.

____________________________________
Signature

_________________________
Date

State of ________________)
County of ______________)
Signed and sworn to before me this ____ day of __________________ of 20___.
_________________________________
Signature of Notary Public
(Notarial Seal)

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My commission expires: _____________________

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DIRECTIONS
If you need assistance in completing this Form or have any questions, please contact:
Name:
Federal Home Loan Bank of
Address:
Telephone:
Fax:
E-Mail:
Who Must File and When
The Federal Home Loan Bank (Bank) uses the information you provide on this Form to
determine whether you meet the statutory and regulatory eligibility requirements to serve as a
member director. You can find these requirements in section 1427 of Title 12 of the United
States Code (12 U.S.C. § 1427) and in part 1261 of Title 12 of the Code of Federal Regulations
(12 C.F.R. part 1261). A copy of the statutory and regulatory eligibility requirements is enclosed
for your reference. Only individuals who satisfy these requirements may run for a member
directorship or serve as a member director.
Nominees for a Member Bank Directorship
If you wish to accept a nomination to serve as a member director, you must complete this Form
and return it to the Bank on or before ___________________. If you do not submit this Form to
the Bank by the deadline, you will be deemed to have declined the nomination.
Incumbent Member Bank Directors
Every year, each incumbent member director must complete this Form and return it to the Bank
on or before March 1st. The Bank will use the information to confirm your continued eligibility
to serve as a member director. If you do not submit this form by the March 1st deadline, the
Bank may declare that you are no longer eligible to serve as a member director, and may declare
vacant the member directorship that you hold. If March 1st falls on a Saturday, Sunday, or
federal holiday, you have until the next business day to submit the completed Form.
Individuals Selected to Fill a Vacancy
If the Bank selected you to fill a vacancy on the board of directors, you must complete this Form
and return it to the Bank on or before _______________. You cannot become a member
director unless you complete and return the Form to the Bank.

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FEDERAL HOME LOAN BANK MEMBER DIRECTOR ELIGIBILITY CERTIFICATION FORM: DIRECTIONS

Line-by-Line Instructions
LINE 1. Print or type your full name.
LINE 2. You must be a United States citizen in order to serve as a member director. Check the
appropriate answer.
LINE 3. Provide the address of your principal residence.
LINE 4. You must be an officer or a director of an institution that is a member of the Bank in
order to be a member director of that Bank. In addition, the member must be located in the state
within the Bank district that is to be represented by the directorship you wish to hold. In most
cases, a member will be deemed to be located where it maintains its home office or its principal
place of business. Provide the requested information for the member you serve as an officer or
director, as well as your title or position at that institution.
LINE 5. If you are an officer or director of any other institution that is a member of this or any
other Bank, provide the name and location of the institution(s), as well as the position that you
hold at the institution(s).
LINE 6. In order for you to be eligible to serve as a member director, every institution that
you serve as an officer or director that is a member of the Bank in which you wish to hold a
directorship must be in compliance with all of its applicable minimum capital requirements
established by its appropriate federal or state regulator. The term “appropriate federal
regulator” has the same meaning as the term “appropriate Federal banking agency” in
section 3(q) of the Federal Deposit Insurance Act (12 U.S.C. § 1813(q)) and, for federally
insured credit unions, means the National Credit Union Administration. The term
“appropriate state regulator” means any state officer, agency, supervisor, or other entity that
has regulatory authority over, or is empowered to institute enforcement action against, a
member.

Check the appropriate answer as to whether each institution you listed in LINE 4 and
LINE 5 is in compliance with all of the applicable minimum capital requirements
established by its appropriate federal or state regulator. If the answer is No, you must list
each non-compliant institution regardless of the Bank of which it is a member. However,
your status as an officer or director of a non-compliant institution will render you ineligible
to serve as a Bank director only if that institution is a member of the Bank in which you
wish to hold a directorship.
Privacy Act Statement: In accordance with the Privacy Act (5 U.S.C. 552a), the following notice is provided. This information is solicited
under authority of 12 U.S.C. 1427(a) and (b); and 12 CFR 1261.5, 1261.7, and 1261.10 to 1261.13. Furnishing the information on this form
is voluntary, but failure to do so may result in you not meeting the statutory and regulatory eligibility requirements to serve as a member
director. The purpose of this information is to facilitate the timely determination of your eligibility to serve as a member director. Information
may be disclosed in accordance with the routine uses identified in FHFA-System of Records Notice FHFA-8 Federal Home Loan Bank
Directors, which may be found at https://www.fhfa.gov/SupervisionRegulation/Rules/Pages/Privacy-Act-of-1974-System-of-Records-Noticeof-the-Establishment-of-New-Systems-of-Records.aspx.
Paperwork Reduction Act Statement: Notwithstanding any other provision of the law, no person is required to respond to, nor shall any
person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction
Act, unless that collection of information displays a currently valid OMB Control Number.

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