Form FR 2081b FR 2081b Interagency Notice of Change in Director or Senior Execu

Board of Governors of the Federal Reserve System OMB Number 7100-0134 Approval expires December 31, 2017
Federal Deposit Insurance Corporation
OMB Number 3064-0097 Approval expires August 31, 2015
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 Director or
Senior Executive Officer—FR 2081b
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
Who Must File
This Notice is used, as required by Section 32 of the Federal
Deposit Insurance Act (Act) (12 U.S.C. § 1831i), by a depository
institution or its holding company to notify the appropriate
regulatory agency of a proposed change in the board of directors
or senior executive officer of such institution or holding company.
In general, this requirement is applicable to a depository
institution or depository institution holding company that:

For additional information regarding the processing procedures
and guidelines and any supplemental information that may be
required, please refer to the appropriate regulatory agency's procedural guidelines (i.e., Comptroller's Corporate Manual, the
FRB's Processing Applications Through the Federal Reserve
System and the Applications Procedures Manual, the FDIC's
Rules and Regulations (12 C.F.R. § 303.14) and relevant policy
statements, or contact the agency directly for specific instruction.

• is

not in compliance with all minimum capital requirements
applicable to such institution, as determined by the appropriate
regulatory agency on the basis of such institution or holding
company's most recent report of condition, report of examination
or inspection;

• is in troubled condition; or
• the appropriate regulatory

agency determines, in connection
with its review of a capital restoration plan required under
Section 38 of the Act (12 U.S.C. § 1831o) or otherwise, that
such prior notice is appropriate.

Preparation
The depository institution or its holding company (filer) should
complete this Notice by providing a response to each of the
questions and signing the Certification for each proposed
individual. Information should be provided as of the Notice's
submission date. In addition, each proposed individual must
complete the biographical and certification portions of the
Interagency Biographical and Financial Report. The filer and
each proposed individual are responsible for understanding the
requirements and the accuracy of the statements. The completed
form(s) should be sent to the appropriate regulatory agency.

Confidentiality
In general, requests for confidential treatment of specific portions
of the application must be submitted in writing concurrently with
the submission of the application and must discuss the
justification for the requested treatment. Applicant's reasons for
requesting confidentiality should specifically demonstrate the
harm (e.g., to its 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 application
(by reference to the confidential section); (2) separately bound;
and (3) labeled "Confidential." Applicant should follow the same
procedure regarding a request for confidential treatment with
regard to the subsequent filing of supplemental information to the
application.
An Applicant should contact the appropriate regulatory agency for
specific instructions regarding requests for confidential treatment.
The appropriate regulatory agency will determine whether the
information submitted as confidential will be so regarded and will
advise the Applicant of any decision to make available to the
public information labeled as "Confidential."

Public reporting burden for the collection of information in this Notice is estimated to average 2 hours per response, 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: Office of the Executive Secretary, 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 Policy and Systems 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.
12/2014

FR 2081b
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Interagency Notice of Change in Director or Senior Executive Officer
Details of Proposed Transaction:

Full Name of Individual

Notice to serve as a:

Director
Senior Executive Officer
Title

Reason:

To replace

; or
Name of Individual

To fill a new position.
Type of filing:

Prior Notice

After-the-Fact Notice

Waiver Previously Granted

Name of Depository Institution or Holding Company

Street

City

County

State

Zip Code

1. Describe the steps taken by the depository institution or holding company to investigate and satisfy itself as to the competence,
experience, character, and integrity of the subject individual. Summarize the individual's qualifications for the proposed position.

2. If this Notice represents a proposal to serve as a senior executive officer of a depository institution or holding company:
(a) Describe the duties and responsibilities of the subject position or attach a position description, if applicable.

(b) Discuss the proposed terms of employment of the subject individual and attach a copy of all pertinent documents, including
any applicable employment contract or compensation arrangement.

12/2011

FR 2081b
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Privacy Act Notice
A copy of this document is provided to the appropriate regulatory agency as required under Section 32 of Federal Deposit Insurance Act
(12 U.S.C. § 1831i). To the extent that it contains personal and financial information concerning proposed directors or senior executive
officers of a depository institution or holding company, the information may be subject to the Privacy Act of 1974 (5 U.S.C. § 552a)
concerning safeguarding personal information.
This information is required to enable the appropriate regulatory agency to evaluate each proposed addition of any individual to the
board of directors or the employment of any individual as a senior executive officer and determine whether or not to disapprove it. A
failure to provide this information could result in disapproval of such a proposal or a determination that the legal requirement of prior
notice has not been satisfied. This document is a public document and may be 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 document would be disclosed to the public and its treatment of confidential information.

Certification
I certify that the information provided in this Notice has been carefully examined by me and is correct, complete, and made in good
faith. The biographical information included in the attached Interagency Biographical and Financial Report has been reviewed, and it is
consistent with the information obtained by the depository institution or holding company. 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
Day

,
Month

.
Year

Signature of Authorized Representative

Name of Authorized Representative

Title of Authorized Representative

Area Code / Phone Number

Area Code / FAX Number

12/2011