Form FR 2081a FR 2081a Interagency Notice of Change in Bank Control

Board of Governors of the Federal Reserve System OMB Number 7100-0134 Approval expires December 31, 2017
Federal Deposit Insurance Corporation
OMB Number 3064-0019 Approval expires July 31, 2017
Office of the Comptroller of the Currency
OMB Number 1557-0014 Approval expires January 31, 2017
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Board of Governors of the Federal Reserve System

Interagency Notice of Change in Control—FR 2081a
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
Preparation and Use
This form is used to file notice to acquire control of a depository
institution or a holding company, pursuant to the Change in Bank
Control Act, as amended (12 U.S.C. § 1817(j)). As used in this
form, "holding company" means a bank holding company, a savings and loan holding company, or other company that controls a
depository institution. The information must be submitted to the
appropriate regulatory agency of the institution whose shares are
to be acquired. All inquiries on preparation of the notice should
be directed to that agency which, in some circumstances, may
modify the information requested.
The regulatory agency will review the submitted notice to determine if it is complete. If the submitted notice is not complete, the
regulatory agency may either request additional information or it
may return the notice. If the required information is not available,
please explain. When the notice is complete, the regulatory
agency will confirm its determination in writing. The questions are
not intended to duplicate information supplied on another form or
in an exhibit; a cross-reference to the information is acceptable.
Any cross-reference must be made to a specific location in the
documents, so the information can be found easily. If additional
space is needed to provide complete answers, please attach
additional sheets or exhibits.
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, Comptroller's Licensing Manual, the FDIC's
Rules and Regulations (12 C.F.R. Part 303) and relevant policy
statements), contact the agency directly for specific instruction,
or visit its Website at www.occ.treas.gov, www.fdic.gov, or
www.federalreserve.gov.
Biographical and Financial Report
To assist the regulatory agencies in evaluating the factors specified in the Change in Bank Control Act, an Interagency
Biographical and Financial Report must be submitted for each
person named in the notice.
Supporting Information
The formal questions in the notice are not intended to limit the
acquirer's presentation, and the regulatory agency may request
additional necessary information. If any information furnished in the

notice changes materially during the processing of the notice or
prior to consummation, such changes should be communicated
promptly to the regulatory agency with which the notice was filed.
Compliance
The proposed acquirer is expected to comply with all representations and commitments made in this notice.
Transactions subject to the Hart-Scott-Rodino Antitrust
Improvements Act of 1976 (15 U.S.C. § 18a), which applies to
certain very large transactions, require a pre-merger filing with
the Federal Trade Commission and the Department of Justice.
Notice of Publication
An acquirer must publish an announcement of the proposed
acquisition in a newspaper of general circulation in the community in which the head office of the depository institution or
holding company is located. In the case of a bank holding company, an announcement also must be published in each community in which the head office of a bank subsidiary of the holding company is located. A copy of the affidavit(s) of publication
should be submitted to the appropriate regulatory agency.
Contact the appropriate regulatory agency for the specific
requirements of the notice of publication.
Confidentiality
Any acquirer desiring confidential treatment of specific portions of the
notice must submit a request in writing with the submission
of the notice. The request must discuss the justification for the
requested treatment. An acquirer'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. § 552). Information for which confidential treatment is requested should be (1) specifically identified in the
public portion of the notice (by reference to the confidential section); (2)
separately bound; and (3) labeled "Confidential." An acquirer should
follow the same procedure for a request for confidential treatment for
the subsequent filing of supplemental information to the notice.
An acquirer should contact the appropriate regulatory agency for
specific instructions regarding requests for confidential treatment.
The appropriate regulatory agency will determine whether the information will be treated as confidential and will advise the acquirer of
any decision to publicly release information labeled as "Confidential."

Public reporting burden for the collection of information for this notice is estimated to average 30 hours, including the 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, SW, Washington, DC 20219; and to the Office of Management and
Budget, Paperwork Reduction Project, Washington, DC 20503.
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FR 2081a
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Interagency Notice of Change in Control—Continued
1. Identify:
a. Name and address of proposed acquirer(s):
(If an individual, provide last name, first name, and middle name)
(If a corporation or other entity, provide the full legal name and the type of organization, for example, ABC Company,
a corporation, or ABC, a partnership)

Name

Street Address

City

State

Zip Code

b. Name and address of depository institution or holding company whose shares are to be acquired:
Name

Street Address
City

State

Zip Code

c. Name, title, employer, address, telephone number, fax number, and e-mail address of the person to whom inquiries
concerning this notice may be directed:
Name

Title

Employer

Street Address

City

Area Code / Phone Number

State

Area Code / FAX Number

Zip Code

E-mail Address

2. Is this notice being filed prior to the acquisition of control?

Yes

No

If the response is no, state the nature of the exception upon which the acquirer is relying for an exception to the prior notice requirement. If no exception is available, please discuss the reason(s) that prior notice was not given and modify the wording of the form as
appropriate to provide all necessary information related to the transaction.

3. For each class of voting securities of the depository institution or holding company to be acquired, provide the total number of
voting shares:
a. Authorized
Shares

b. Currently outstanding
Shares

c. Pro forma outstanding
Shares
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FR 2081a
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Interagency Notice of Change in Control—Continued
4. Provide the following information. For any shares registered or to be registered in another name (such as a trust, corporation, or
partnership), indicate the names of registered parties, beneficial owners and trustees, as applicable.

Number of shares
per class of securities
now owned,
controlled, or held

Full name of each acquirer or transferee

Number of shares per
class of securities to
be purchased by or
transferred to the
acquirer or transferee

Number of shares per
class of securities
after completion of
acquisition

TOTAL
Total as percent of shares outstanding per class of securities

5. Indicate:
a. The purchase price(s) per share of shares to be acquired $
b. Total purchase price for the entire proposed transaction

$

c. The current book value per share

$

d. The current market value per share
(including date and source of information, if available)

$

6. Discuss the proposal, including the purpose, terms, and conditions of the acquisition, and the manner in which the acquisition will be
made. Summarize and attach copies of all pertinent documents, such as purchase and sale agreements, shareholder agreements,
non-compete agreements, employment contracts, and trust agreements.

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FR 2081a
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Interagency Notice of Change in Control—Continued
7. Provide the following information.
Name of each acquirer or transferee

Total purchase price

Source of funds

Amount of funds

$

TOTAL

$

a. If cash funds will be used, provide copies of checking, savings, or money market account statements. If assets will be liquidated,
list those assets and provide a copy of the documents that can verify the timing of such transaction and the amount of the
anticipated proceeds.

b. If any portion of the funds (or other consideration) for the acquisition will be borrowed, indicate the name of each borrower, name
and address of each lender, amount financed, collateral to be pledged, and terms of the transaction, including interest rates,
amortization requirements, guarantors, endorsers, co-makers, and any other arrangements, agreements, and understandings
between and among the parties. If applicable, submit a copy of any loan commitment letter.

c. Indicate the means through which the borrowed funds will be repaid. Provide details if the acquirer will rely on salaries, dividends,
fees, or other funds from the depository institution or holding company to be acquired.

8. Provide the following information.

Name of each seller or transferor

Number of shares
per class of voting
securities now
held

Number of shares per
class of voting
securities to be sold or
transferred

Number of shares per
class of voting securities
after completion of
acquisition

TOTAL
Total as percent of total shares outstanding per class of
securities
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FR 2081a
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Interagency Notice of Change in Control—Continued
9 . Identify any person or parties employed, retained, or to be compensated by any acquirer, or by any person on behalf of any acquirer,
to make solicitations or recommendations to stockholders and thereby assist in the acquisition. Include a description of the terms of
such employment, retainer, or arrangement for compensation, and provide a copy of any such agreement or contract.

10. List and provide copies of all invitations, tenders, or advertisements making a tender offer to stockholders for purchase of their
stock in connection with the proposed acquisition.

11. Describe in detail any plans or proposals that any acquirer may have to: (a) liquidate the depository institution or holding company
to be acquired, (b) sell its assets, (c) merge it with any company, or (d) make any other significant change in its business strategy or
corporate structure.

12. If changes are contemplated in the board of directors or senior executive officers of the depository institution or holding company to
be acquired, provide a current and pro forma list of officers and directors. The regulatory agency with which this notice has been
filed should be contacted to determine the filing or other information requirements associated with changes to the board of directors
or senior executive officers, pursuant to Section 32 of the Federal Deposit Insurance Act (12 U.S.C. § 1831i).

13. For each acquirer, indicate any positions currently held (director, officer, or employee) in any other depository institution or holding
company. Also indicate if any acquirer directly or indirectly (such as through personal trusts, corporations, or similar arrangements)
owns, controls, or has power to vote 10 percent or more of any class of voting securities or other voting equity interests of any
other depository institution or holding company.

Name of each
acquirer or transferee

Name and address of each
depository institution or
holding company

Position and
Date appointed

Percent
ownership of
institution

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Interagency Notice of Change in Control—Continued
14. If any office of any depository institution or holding company with which the acquirer is currently associated is located in the same
geographic market as the subject institution, provide the name and location of each office of such other organization.

15. If the proposed acquirer is not an individual (or a group of individuals acting in concert) and the acquirer is engaged, directly or
indirectly (including through a subsidiary), in insurance activities that are supervised by a state insurance regulator, provide:
a. The name of the company.

b. A description of the insurance activity that the company is engaged in and has plans to conduct.

c. A list of each state and the lines of business in that state in which the company holds, or will hold, an insurance license.
Indicate the state where the company holds a resident license or charter, as applicable.
State

Line of Business

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FR 2081a
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Interagency Notice of Change in Control—Continued
Privacy Act Notice
A copy of this document is provided to the appropriate regulatory agency as required under 12 U.S.C. § 1817(j) and implementing regulations. This notice, including supporting material, is available to the public upon request under the provisions of the Freedom of
Information Act (5 U.S.C. § 552). Contact the appropriate regulatory agency for the specific procedures under which the notice would be
disclosed to the public. To the extent that it contains personal and financial information concerning individual acquirers of depository
institutions and holding companies, the information may be subject to the Privacy Act of 1974 (5 U.S.C. § 552a), which provides safeguards for personal information. The applicability of the Privacy Act to the information provided on this document will depend on the
manner in which the appropriate federal banking agency maintains such information.
This form solicits information that will enable the regulatory agencies to evaluate and make a decision on each proposed change in control under the standards prescribed by the Change in Bank Control Act. Failure to provide information requested in connection with the
processing of this notice could result in disapproval of a proposed acquisition or a determination that complete notice has not been submitted. Any person acquiring control of a depository institution or holding company without filing a notice prior to the proposed acquisition may be subject to substantial civil money penalties. The Change in Bank Control Act requires the regulatory agencies processing
this notice to furnish copies of this information to other federal and state banking authorities. Where possible violations of laws or regulations are disclosed, relevant information may be made available to other regulatory agencies or other law enforcement or governmental agencies. Identification of parties to a proposed transaction and details of that transaction, to the extent material to the regulatory
agency's determination, may be incorporated in orders and notices issued under the Change in Bank Control Act or otherwise made
public.

Certification
This notice must be signed by each acquiring party, or by at least two directors, officers, partners, or others authorized to sign on behalf
of an acquiring party that is not an individual.
I certify that the information contained in this notice has been examined carefully by me and is true, correct, and complete, and is
current as of the date of this submission. 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.
I acknowledge that final action on this notice is in the discretion of the appropriate federal banking agency. Actions or communications,
whether oral, written, or electronic, by an agency or its employees in connection with this filing do not constitute a contract, either
express or implied, or any other obligation binding upon the agency, other federal banking agencies, the United States, any other
agency or entity of the United States, or any officer or employee of the United States. Such actions or communications will not affect the
ability of any federal banking agency to exercise its supervisory, regulatory, or examination powers under applicable law and
regulations. I further acknowledge that the foregoing may not be waived or modified by any employee or agent of a federal banking
agency or of the United States.

Signed this

day of
Day

,
Month

.
Year

Signature

Signature

Print or type name

Print or type name

Title (if applicable)

Title (if applicable)

12/2011