Interagency Biographical and Financial Report

Board of Governors of the Federal Reserve System OMB Number 7100-0134 Approval expires September 30, 2013
Federal Deposit Insurance Corporation
OMB Number 3064-0006 Approval expires April 30, 2014
Office of the Comptroller of the Currency
OMB Number 1557-0014 Approval expires November 30, 2013
Page 1 of 16

Board of Governors of the Federal Reserve System

Interagency Biographical and Financial Report-FR 2081c
DRAFT 6/7/17 Showing all changes
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 infor- mation
is acceptable. Any cross-reference must be made to a spe- cific cite
or location in the documents, so the information can be located
easily. Use additional sheets as necessary. Each regula- tory
agency will provide additional instructions for use and prepa- ration.
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 i n d i v i d u a l as well as the filing of additional
information or state- ments, 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 (for example, the OCC’s Rules and
Regulations (12 C.F.R Part 5), the Comptroller's Licensing Manual, the
FDIC's Rules and Regulations (12 C.F.R. Part 303), the Federal
Reserve’s Regulations Y and LL (12 C.F.R. Part 225 and 12 C.F.R. Part
238, respectively), 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.
For additional information regarding the processing procedures
and guidelines and any supplemental information that may be
required, refer to the appropriate regula- tory 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 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.

1. A company seeking to acquire direct or indirect control of a bank or savings association thrift should consult with the appropriate regulatory agency for filing
instructions.
2. Provide the foreign currency exchange rate and conversion date, if applicable.
12/2011

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, Office of the
Comptroller of the Currency, 400 7th St. SW250 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 2081c
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General Information and
Instructions-Continued
Associated means associated as an officer, director, organizer,
partner, trustee, principal shareholder or owner.
Company means any corporation, association, partnership, lim- ited
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.

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 u n d e r t h e F r e e d o m o f
I n f o r m a t i o n A c t (5 U.S.C. § 552). Information for which
confidential treatment is requested should be: (1) specifi- cally
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 treat- ment.
The agency will determine whether the information will be treated
as confidential and will advise the individual of any deci- sion to
make available to the public information labeled "Confidential."

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.

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FR 2081c
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This is filed with respect to:
Name of Subject Institution or Holding Company

(Location City,State

Position (Check all that apply)

Type of Filing (Check all that apply)

D

D

Bank or Savings AssociationThrift Charter
D Bank or Savings and LoanThrift Holding
Company
D  Change in Bank Control1
D  Change in Senior Executive Officer or
Director
D Citizenship Waiver
D  Charter Conversion
D  Deposit Insurance
D Federal Branch or Agency
D  Other

D
D

Organizer
Director
Senior Executive Officer

Title

D
D
D

D

Principal Shareholder
 Trustee
 Manager
 Other

Biographical Report
1. Personal Information

a. Name

--------------------------------------

Last

First

Middle (Full name, 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.

1

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

For any shares in a company in which an
individual holds jointly with one or more persons,
each party must complete the full biographical

section of the form. The parties may choose to submit individual or
joint financial statements.
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FR 2081c
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d. Date of Birth
Month I Day I Year

e. Place of Birth
City

State/Province

Country

f. United States Social Security Number

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FR 2081c
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g. Citizenship
-----------------------------

Country

Date, if Naturalized

Are you a United States citizen?

Yes

No

Date, if naturalized:

h. If not a United States citizen, or you have dual citizenship, provide:
Country of Citizenship

---------------------------------------------------------

Passport Number/Ex
pi
Expiration Date __________________
Home Country Identification Number
Immigration File Number

___________________________________________________

Father's Full Name
Mother's Full Name, including maiden name

-----------------------------------

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 I FAX Number

E-mail Address

ij. 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

Beginning Date

Ending Date

2. Employment Record

a. List employment in reverse chronological order for the last fivef i v e t e n years. . Provide the following information. 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.( If the applicant has additional relevant employment experience, or additional
information to support the application, provide an attachment.)

_________ __________ _________________________ __________________ _____________ ___________
Beginning Date

Ending Date

Employer’s Name

Street

City

State/Prov.

________________________________ ________________________ _______________________________________________________
Nature of Business
Title or Position
Nature of Duties
_______________________________________________________________________________________________________________
Reason for Leaving

_________ __________ _________________________ __________________ _____________ ___________
Beginning Date

Ending Date

Employer’s Name

Street

City

State/Prov.

________________________________ ________________________ _______________________________________________________
Nature of Business
Title or Position
Nature of Duties
_______________________________________________________________________________________________________________
Reason for Leaving

_________ __________ _________________________ __________________ _____________ ___________
Beginning Date

Ending Date

Employer’s Name

Street

City

State/Prov.

________________________________ ________________________ _______________________________________________________
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FR 2081c
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Nature of Business

Title or Position

Nature of Duties

_______________________________________________________________________________________________________________
Reason for Leaving

Beginning Date

Ending Date

Employer's Name

Title or Position

City

Beginning Date

Ending Date

State / iProv.

Employer's Name

Title or Position

City

Beginning Date

Ending Date

State / iProv.

Employer's Name

Ending Date

State / iProv.

Employer's Name

Ending Date

Nature of Business

Title or Position

City

Beginning Date

Nature of Business

Title or Position

City

Beginning Date

Nature of Business

State / iProv.

Employer's Name

Nature of Business

Title or Position

City

State / iProv.

Nature of Business

Nature of Duties

Reason for Leaving

Nature of Duties

Reason for Leaving

Nature of Duties

Reason for Leaving

Nature of Duties

Reason for Leaving

Nature of Duties

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
following information:.

_______________________ __________________ _____________ _____________ ______________________
Employer’s Name

Street

City

State/Prov.

Area Code / Phone Number

____________________________________ ______________________________ ______________________________________________________________________________
Title or Position
Date of Discharge
Explanation

Employer's Name

Address

Title or Position

Date of DischargeCode / Phone number

Area Code I Phone Number

_____________________________________________________________________________________________________________________________________________
Explanation

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FR 2081c
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3. Education and Professional Credentials
a. List each diploma or degree from high schools, colleges, universities, or other schools.
School's Name

AddressSchocol's Location

School's Name

A d d r e s s Schocol's Location

School's Name

A d d r e s s Schocol's Location

Date From

Date To

Degree

Date From

Date To

Degree

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 currently associated, a n d p r o v i d e providing the the following information:
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
Business

AddressLocation

Nature or Type of
%

Position Held or Relationship to the Company

Ownership Percentage

Company Name

Start Date

Nature or Type of Business
Location

%

Address

Ownership Percentage

Start Date

Position Held or Relationship to the Company
Nature or Type of Business
%

Company Name
Location
Address

Ownership Percentage

Start Date

Nature or Type of Business

Position Held or Relationship to the Company

%
Ownership Percentage

Company Name

Start Date

Location
Address

Position Held or Relationship to the Company

b. List the name of any depository institution or depository institution holding company with which you are n o w a s s o c i a t e d or were
associated and for which is not listed in your response to 4a above..and provide the following information:
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

Address Location

Nature of Banking Activity

Depository Institution/Holding Company Name

Position Held or Relationship

Location

Position Held or Relationship

Depository Institution/Holding Company Name
AddressL
ocation

Depository Institution/Holding Company Name

Location

Position Held or Relationship
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FR 2081c
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Position Held or Relationship
%
Ownership Percentage

Start Date

End Date

Nature of Banking Activity
%
Ownership Percentage

Start Date

End Date

Nature of Banking Activity
%
Ownership Percentage

Start Date

End Date

Nature of Banking Activity
%
Ownership Percentage

Start Date

End Date

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FR 2081c
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c. Are you in the process of being considered for a senior executive officer, or director, or management official 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 an application has been submitted for regulatory review, provide the name of the regulatory agency.

Depository Institution I 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 (If you answer yes to any question, see also question 5g)
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

 No

(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 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
connection with the transaction?
 Yes
 No

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FR 2081c
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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
company?
 Yes
 No
(2) Defaulted on a loan or financial obligation of any sort, whether as obligor, cosigner, or guarantor?

 Yes

(3) Forfeited property in full or partial satisfaction of any financial obligation?

 Yes

(4)

(6)

Failed or refused to pay any outstanding judgments?

 Yes
 Yes

 No

 Yes

Had a lien placed against property for failure to pay taxes or other debts?

(5) Had wages or income garnished for any reason?

 No
 No

 No
 No

(7) Failed to satisfy any federal, state or local tax
obligations?
Yes
No

e. Have you or any company or depository institution with which you are or were associated been involved in any c r i mi n a l o r
c i v i l 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, suspension, removal,
disbarment, or revocation of
license), agreement (including a deferred prosecution agreement, consent order, written agreement or memorandum of
understanding), undertaking, consent, judgment, or order imposed by or entered into with any of the following entities:
(1) Any state, federal or f o r e i g n state court?

Yes

 No

(2) Any department, agency, or commission of the United States government?
(3) Any state, municipal, or foreign governmental entity?

 Yes

Yes

 No

Yes

 No

 No

(4) Any self-regulatory organization (for example, NASD, FASB, state bar)?

f. Have you or any company or depository institution with which you are or were associated ever 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 including, but not limited to, driving under the influence, reckless driving and
disorderly conduct). Note that driving under the influence is not a minor traffic violation)?
 Yes  No
g. Has any company or depository institution in which you are or were associated been charged with, indicted for, or convicted of
(including a conviction where the record was expunged), or ever pleaded nolo contendere to, any criminal matter?
h. Have you ever been disbarred and/or had a professional license revoked?

___Yes

No

g.hi If you answer "yes" to any question in 5(a) through 5(fhf), provide your explanation by identifying the number of the
question, describing the situation in detail (providing supplemental documentation as appropriate), and, where relevant,
including the:
•
•
•
•
•
•
•
•
•
•
•

Date of any relevant event.
Name and location of any institution, company, party, court, regulatory agency, or self-regulatory organization involved.
Name and location of any institution, company or party 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, conviction, or finding.
Jurisdiction and court in which any legal proceeding occurred.
Resolution or disposition of the matter.

For any of the mattersbankruptcy noted above, the response should indicate whether any insured depository institution suffered a loss as a result. If so,
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16

identify the insured depository institution and the amount of the loss, and indicate whether the institution was ever made whole.

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16

68. 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.

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16

Financial Report
The values in the financial statement below must agree with the total values in the following supporting schedules.
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,) current
market value)

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 $$`

*For any debt reported on any of the supporting schedules, indicate any liability that is contractually delinquent and
provide a discussion on how the delinquency will be resolved.

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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 contingently liable for the debts of others or through a pending lawsuit?
 Yes
 No
If "yes," complete the following:

Debtor or Obligor

Creditor or Obligee

Name

Name

Address

Address

Name

Name

Address

Address

Name

Name

Address

Address

Name

Name

Address

Address

Description and Value of
Collateral

Date Due

Current Amount

$

TOTAL $

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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 B8-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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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.. Discuss the basis for the
valuations used.

Description and Address
of Property Location
(City and State)

Owner of
Property

Percent
Ownership

Mortgage
Holder

%

--- --

%

Current M a r k e t
Value2

$

$

TOTAL $

$

--- -- %
--- --

Current
Mortgage
BalanceMar
ket Value11

Maturity
Date

--- -- %
--- --

%

1. Carry Total forward to Liabilities Assets,-Real estate mortgages
2. Carry Total forward to Liabilities Assets,-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 $

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Schedule E-Other Assets
Include retirement funds (for example, 401K, IRA, Keogh), a n d a s s e t s n o t h e l d b y b u s i n e s s e s l i s t e d o n S c h e d u l e D
i n c l u d i n g 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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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. Indicate any liability that is contractually delinquent by
placing an asterisk next to the current balance and provide a discussion on how the delinquency will be resolved.
Payable To

Description

Maturity Date

Current Balance

$

TOTAL $

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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.

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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. § 18170) (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 rel- evant
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.

Certifications
Biographical and Financial Report Certification (Individual Applicant)
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

Signature 1

Print or Type Name

Print or Type Name

Title (if applicable)

Title (if applicable)

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FR 2081c
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Financial Report Certification (If filing joint financial statements, Individual Applicant’s spouse must complete the
following certification.)
I understand that the appropriate regulatory agency may conduct extensive background checks in conjunction with the information
contained in the joint financial report. I certify that the information contained in the joint 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

Signature 1

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