Form NCUA 3250 NCUA 3250 Application to Request Consent Pursuant to Sec. 205(d)

OMB No. 3133-XXXX

NATIONAL CREDIT UNION ADMINISTRATION
APPLICATION TO REQUEST CONSENT PURSUANT TO SECTION 205(d)
Public reporting burden for this collection of information is estimated to average 2 hours for biographical 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: Office of General Counsel, National Credit Union
Administration, 1775 Duke Street, Alexandria, Virginia 22314 and to the Office of Management and Budget,
Paperwork Reduction Project, Washington, DC 20503. An organization or a person is not required to respond to a
collection of information unless it displays a currently valid OMB control number.

Section 205(d)(1) of the Federal Credit Union Act (12 U.S.C. § 1785(d)(1)), provides
that, except with the prior written consent of the National Credit Union Administration
(NCUA) Board, a person who has been convicted of any criminal offense involving
dishonesty or breach of trust, or has agreed to enter into a pretrial diversion or similar
program in connection with a prosecution for such offense may not:
 become, or continue as, an institution affiliated party
with respect to any insured credit union; or
 otherwise participate, directly or indirectly, in the
conduct of the affairs of any insured credit union.
Section 205(d)(1)(B) further provides that an insured credit union may not allow any
person described above to engage in any conduct or to continue any relationship
prohibited by Section 205(d). Section 205(d)(3) states that “whoever knowingly
violates” (d)(1)(A) or (d)(1)(B) is committing a felony, punishable by up to five years in
jail and a fine of up to $1,000,000 a day. The statute also prescribes a minimum tenyear prohibition period for certain offenses.
The NCUA Board issued Interpretive Ruling and Policy Statement 08-1 (IRPS 08-1),
entitled Guidance Regarding Prohibitions Imposed by Section 205(d) of the Federal
Credit Union Act, to assist the credit union community in requesting the NCUA Board’s
consent pursuant to Section 205(d). IRPS 08-1 is available on NCUA’s website at
https://www.ncua.gov/files/publications/irps/IRPS2008-1.pdf, by contacting NCUA’s
Publications Department at 703-518-6340 or from any NCUA Regional Office.
All requests for the NCUA Board’s consent pursuant to Section 205(d) should be
submitted using the attached form. Please consult IRPS 08-1 prior to completing the
attached application, as not all criminal convictions require an application to be
submitted. IRPS 08-1 also lists the factors the NCUA Board will consider when
evaluating any application for consent.
Any questions regarding the process to request the NCUA Board’s consent pursuant to
Section 205(d), including whether an application is required, may be directed to NCUA’s
Office of General Counsel at 703-518-6540 or by email at [email protected].
Completed applications should be sent to the appropriate NCUA Regional Office.

NCUA Form 3250 (8-2008)

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NATIONAL CREDIT UNION ADMINISTRATION
APPLICATION PURSUANT TO SECTION 205(d) OF THE FEDERAL CREDIT UNION ACT

SECTION A – APPLICANT CREDIT UNION INFORMATION

1. Name of Credit Union:

2. Date of Application:
3. Address of Credit Union: (Street, City, County, State and Zip Code)

We have, in connection with preparing this Application, read Sections 205(d)(1) & (3) of the Federal Credit Union Act (12
U.S.C. §§ 1785(d)(1) & (3)) which governs requests by insured credit unions for the consent of the National Credit Union
Administration Board for a person who has been convicted of a crime involving dishonesty or breach of trust, or who has
agreed to enter into a pretrial diversion or similar program in connection with a prosecution for such offense, to become or
continue as an institution-affiliated party, or otherwise participate, directly or indirectly, in the conduct of the affairs of an
insured credit union,
In support of this Application, the following statements, representations and information are submitted for the purpose of inducing
the National Credit Union Administration Board to grant its written consent to the person identified below (hereinafter, the prohibited
person), who has been convicted of a crime involving dishonesty or breach of trust or has agreed to enter into a pretrial diversion or
similar program in connection with a prosecution for such offense, to become or continue as an institution-affiliated party, or
otherwise participate, directly or indirectly, in the conduct of the affairs of this credit union.
SECTION B - BIOGRAPHICAL INFORMATION CONCERNING THE PROHIBITED PERSON

1. Name:

2. Address: (Street, City, County, State and Zip Code)

3. Date of Birth: (Month, day, year)
4. Place of Birth: (City and State)
5. Social Security Number (see Privacy Act Notice on page 4):
6. Name and Address of Present or Most Recent Employer: (Street, City, County, State and Zip Code)

NCUA Form 3250 (8-2008)

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SECTION C - INFORMATION RELATIVE TO THE PROHIBITED PERSON’S CONVICTIONS

1. Description or nature of crime:

a. Date of conviction :

b. Name and address of court:

c. Disposition of the charges:

NOTE: Additional conviction(s) for a crime involving dishonesty or breach of trust discovered subsequent to approval of this
Application will require the submission of another application.
2. Briefly describe the nature of the offense and the circumstances surrounding it. Include age of the prohibited person at the time
of conviction, date of the offense, and any mitigating circumstances (parole, suspension of sentence, pardon, etc.) Attach additional
pages if necessary.

3. Briefly describe the extent of rehabilitation the prohibited person completed (attach supporting documents, if any.)

4. Attach documentation of the Indictment, Information, or Complaint and Final Decree of Judgment, if available. (Normally these
can be obtained from the clerk of the court. If not provided, explain reasons for unavailability).

5. List any other pertinent facts relative to the crime which are not disclosed in the indictment or other court documents. Attach
additional pages if necessary.

NCUA Form 3250 (8-2008)

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I do hereby certify that the Biographical Information Concerning the Prohibited Person (Section B) and Information Relative to the
Prohibited Person’s Convictions (Section C) are true and correct to the best of my knowledge and belief.

___________________________________________________________
SIGNATURE OF THE PROHIBITED PERSON

_____________________
DATE SIGNED

PRIVACY ACT NOTICE
The Privacy Act of 1974 (Public Law 93-579) requires that you be advised as to the legal authority, purpose and uses of the
information solicited by this form. Pursuant to Section 205(d) of the Federal Credit Union Act (12 U.S.C. § 1785(d)), the information
in this form is requested for the purpose of evaluating an application for the consent of the NCUA Board to allow a prohibited person
to participate in the affairs of an insured credit union. NCUA may conduct a more involved background check as part of the
approval process. This form may be disclosed to any of the following sources: any appropriate Federal or State credit union
regulatory agencies and law enforcement or other governmental agencies for identity verification purposes; a congressional office in
response to your inquiry to that office; an appropriate federal, state, or local authority in the investigation or enforcement of a statute
or regulation; or employees of a federal agency for audit purposes. In addition, in the event of litigation, the application may be
presented to the appropriate court as evidence and to counsel in the course of discovery. Failure to complete this form or omission
of any item of information, except for disclosure of your social security number, may result in a delay in the processing of this
application. In accordance with Section 792.68 of NCUA's regulations, you are not required to furnish your social security number
on this form. Your social security number, if voluntarily provided, will be used to more easily verify the information required by this
form. No penalty will result to you or to the credit union if you do not provide your social security number. Falsification of any of the
information may serve as a basis for removal of the prohibited person if employed by the credit union and as grounds for criminal
charges.

NCUA Form 3250 (8-2008)

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SECTION D - POSITION TO BE OCCUPIED BY THE PROHIBITED PERSON

1. Title or Position:

2. Describe the duties and responsibilities of the prohibited person. Include extent of supervision exercised over others and/or by
others. Attach additional pages if necessary.

NOTE: Should this request be approved, any significant change in the duties and/or responsibilities of the prohibited person which
occurs subsequent to approval by the NCUA Board must be reported in writing to the Regional Director of the NCUA Regional
Office in which the credit union is located.
SECTION E - NOTIFICATION OF FIDELITY INSURER
The credit union’s fidelity insurer is to be notified of all pertinent information regarding the conviction of the prohibited person.
Assurances from the insurer must be obtained, in writing, stating that the prohibited person will be covered by the credit union’s
fidelity bond. This application and the information requested herein may be submitted prior to notification of the bonding company.
However, the NCUA Board’s consent will be subject to a condition that written assurance of fidelity coverage to the same extent as
others in similar positions be obtained by the Credit Union.
SECTION F - ADDITIONAL INFORMATION IN SUPPORT OF THIS REQUEST

List any other appropriate information that may be relevant to the NCUA Board’s evaluation of this Application. Attach additional
pages if necessary.

I do hereby certify that the board of directors of the credit union adopted a resolution which delegated the undersigned the authority
to make applications pursuant to Section 205(d) of the Federal Credit Union Act or have adopted a resolution authorizing this
application pursuant to Section 205(d) of the Federal Credit Union Act.

_______________________________________
SIGNATURE OF CREDIT UNION OFFICIAL

____________________________
TITLE

______________
DATE SIGNED

This is an official document of the National Credit Union Administration. Providing false information may be grounds for prosecution
under the provisions of Title 18, Sections 1001 to 1007, of the United States Code and may be punishable by fine or imprisonment.

NCUA Form 3250 (8-2008)

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