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Page 1 of 16
Board of Governors of the Federal Reserve System
Interagency Biographical and Financial Report—FR 2081c
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 individuals1 in conjunction with other corporate filings to
the appropriate regulatory agency. This report is not a standalone 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
market value in United States dollars2 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 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 institution-affiliated 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)), contact the agency directly for specific instruction, or visit its Website at www.occ.treas.gov, www.fdic.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.
1. A company seeking to acquire direct or indirect control of a bank or thrift should consult with the appropriate regulatory agency for filing instructions.
2. Provide the foreign currency exchange rate and conversion date, if applicable.
Public reporting burden for this collection of information is estimated to average 2 hours for biographical information and 2 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, SW, Washington, DC 20219; and to the Office of Management and Budget, Paperwork Reduction Project, Washington, DC 20503.
12/2014
FR 2081c
Page 2 of 16
General Information and
Instructions—Continued
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 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. § 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."
12/2011
FR 2081c
Page 3 of 16
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
Other
Biographical Report
1. Personal Information
a. Name
Last
First
Middle (No Initials)
b. Residence
Street Address
City/Town
State/Province
ZIP/Postal Code
Country
c. If at residence less than five years, list addresses and dates occupied for past five years.
Date From
Date To
Number and Street
City
State/Prov.
ZIP/Postal Code
Country
Date From
Date To
Number and Street
City
State/Prov.
ZIP/Postal Code
Country
Date From
Date To
Number and Street
City
State/Prov.
ZIP/Postal Code
Country
Date From
Date To
Number and Street
City
State/Prov.
ZIP/Postal Code
Country
Date From
Date To
Number and Street
City
State/Prov.
ZIP/Postal Code
Country
d. Date of Birth
Month / Day / Year
e. Place of Birth
City
State/Province
Country
f. United States Social Security Number
12/2011
FR 2081c
Page 4 of 16
g. Citizenship
Country
Date, if Naturalized
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 e-mail address:
Area Code, Telephone Number, including Country Code if outside U.S.
Area Code / 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.
Period of Time Used
Other Names Used
2.
Beginning Date
Ending Date
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.
Beginning Date
Ending Date
Employer's Name
State/Prov.
City
Beginning Date
Ending Date
Employer's Name
State/Prov.
City
Beginning Date
Ending Date
Employer's Name
State/Prov.
City
Beginning Date
Ending Date
Employer's Name
State/Prov.
City
Beginning Date
Ending Date
Employer's Name
State/Prov.
City
Title or Position
Nature of Duties
Nature of Business
Reason for Leaving
Title or Position
Nature of Duties
Nature of Business
Reason for Leaving
Title or Position
Nature of Duties
Nature of Business
Reason for Leaving
Title or Position
Nature of Duties
Nature of Business
Reason for Leaving
Title or Position
Nature of Duties
Nature of Business
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.
Employer's Name
Address
Title or Position
Date of Discharge
Area Code / Phone Number
Explanation
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FR 2081c
Page 5 of 16
3. Education and Professional Credentials
a. List each diploma or degree from high schools, colleges, universities, or other schools.
School's Name
School's Location
Date From
Date To
Degree
School's Name
School's Location
Date From
Date To
Degree
School's Name
School's Location
Date From
Date 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
License
Issuing Authority
Date Issued
Status
Expiration
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.
Company Name
Location
Nature or Type of Business
%
Position Held or Relationship to the Company
Company Name
Ownership Percentage
Location
Start Date
Nature or Type of Business
%
Position Held or Relationship to the Company
Company Name
Ownership Percentage
Location
Start Date
Nature or Type of Business
%
Position Held or Relationship to the Company
Company Name
Ownership Percentage
Location
Start Date
Nature or Type of Business
%
Position Held or Relationship to the Company
Ownership Percentage
Start Date
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.
Depository Institution/Holding Company Name
Location
Nature of Banking Activity
%
Position Held or Relationship
Depository Institution/Holding Company Name
Ownership Percentage
Location
Start Date
End Date
Nature of Banking Activity
%
Position Held or Relationship
Depository Institution/Holding Company Name
Ownership Percentage
Location
Start Date
End Date
Nature of Banking Activity
%
Position Held or Relationship
Depository Institution/Holding Company Name
Ownership Percentage
Location
Start Date
End Date
Nature of Banking Activity
%
Position Held or Relationship
Ownership Percentage
Start Date
End Date
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FR 2081c
Page 6 of 16
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.
Depository Institution / Holding Company Name
Position
Regulatory Agency
Position
d. Are you now or are you proposed to be a "management official" of another insured depository institution or depository institution
holding company?
Yes
No
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) A charter 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 similar position?
Yes
No
(2) A merger application in which you were listed as a director, senior executive officer, or similar position?
Yes
(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
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 organization in which you were listed in some capacity?
Yes
No
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 other governmental entity?
Yes
No
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
Yes
No
connection with the transaction?
12/2011
FR 2081c
Page 7 of 16
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 bankruptcy petition filed against you or the
Yes
No
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
(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
No
(2) Any department, agency, or commission of the United States government?
(3) Any state, municipal, or foreign governmental entity?
Yes
(4) Any self-regulatory organization (for example, NASD, FASB, state bar)?
Yes
No
Yes
No
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.
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FR 2081c
Page 8 of 16
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.
12/2011
FR 2081c
Page 9 of 16
Financial Report
Financial Statement as of
Month / Year
Assets
Liabilities and Net Worth
Cash on hand and in depository institutions
$
$
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)
TOTAL LIABILITIES
Proprietary interests and other securities
(Schedule D)
Net worth
(Total assets less total liabilities)
Retirement funds and other assets
(Schedule E)
TOTAL ASSETS $
TOTAL LIABILITIES AND NET WORTH $
12/2011
FR 2081c
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Contingent Liabilities
In addition to the liabilities listed on the Financial Statement, have you endorsed, guaranteed, or become otherwise indirectly or continYes
No
gently liable for the debts of others or through a pending lawsuit?
If "yes," complete the following:
Debtor or Obligor
Creditor or Obligee
Name
Name
Address
Address
Description and Value of
Collateral
Date Due
Current Amount
$
Name
Name
Address
Address
Name
Name
Address
Address
Name
Name
Address
Address
TOTAL $
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FR 2081c
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Supporting Schedules
Schedules must agree in total with the appropriate item contained in the Financial Statement on page 9
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.
Description
Current Balance
$
TOTAL $
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FR 2081c
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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
.
%
.
%
.
%
.
%
.
%
Current
Market
Value1
Maturity
Date
Current Value2
$
$
TOTAL $
$
1. Carry Total forward to Assets—Real estate
2. 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 $
12/2011
FR 2081c
Page 13 of 16
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
$
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FR 2081c
Page 14 of 16
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 $
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FR 2081c
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Cash Flow Statement1
Year
Sources of Cash
Salaries, wages, commissions,
and other employment income
Projected Current
Year
Year
Projected Next
Year
$
$
$
$
$
$
$
$
Rents, royalties,
and investments
Income from dividends
and interest
Income and other distributions
from partnerships
Other sources2
Total cash received
Uses of Cash
Personal living expenses
(rent, household)
Fixed obligations3
Income taxes
Capital contributions
to partnerships
Other uses2
Total cash outlay
Net Cash Flow (deficit)
1. Discuss any significant changes on a separate page.
2. Itemize on a separate page any items amounting to 10 percent or more of total cash received or total cash outlay.
3. 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.
12/2011
FR 2081c
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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
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
Day
,
Month
.
Year
Signature
Signature1
Print or Type Name
Print or Type Name
Title (if applicable)
Title (if applicable)
1. If a joint financial statement is being submitted, both parties should complete the "Certification."
12/2011
| File Type | application/pdf |
| File Title | FR 2081c |
| Subject | Interagency Biographical and Financial Report |
| Author | Federal Reserve Board |
| File Modified | 2018-05-30 |
| File Created | 2014-12-29 |