Form FR MM-OF FR MM-OF Order Forms

Board of Governors of the Federal Reserve System

DRAFT

FR MM-Form OF
OMB Number
Approval expires January 31, 20XX
Page 1 of X

Order Forms—FR MM – Form OF

The information in this form is required by law: 12 CFR Part 239
(Mutual Holding Companies).

specified in this form in connection with requests from savings
associations to conduct mutual holding company reorganizations. 1

The Federal Reserve System (“FRS”) will use the information

The undersigned hereby certifies that the attached information is consistent with
information contained in other documents that are required pursuant to Regulation MM
(e.g., business plan, stock issuance plan, plan of conversion, reorganization plan, proxy
soliciting materials).

Does applicant request confidential treatment for any portion of
this submission?

Name of Applicant

Yes
Street Address
City

As required by the General Instructions, a letter justifying
the request for confidential treatment is included.
State

Zip Code

The information for which confidential treatment is being
sought is separately bound and labeled "Confidential."
Date of Application:

No

Month / Day / Year

:

.

1
Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time to gather and maintain data in the required form, to
review instructions and to complete the information collection. The FRS may not conduct or sponsor, and an organization is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden to: Secretary, Board of Governors of the Federal Reserve System, 20th and C Streets, NW, Washington, DC 20551; and to the Office of Management and
Budget, Paperwork Reduction Project (7100-0121), Washington, DC 20503.
0x/2019

Name, title, address, telephone number, and email address of person(s) to whom inquiries concerning this form may be directed:
Name

Name

Title/Organization

Title/Organization

Street Address

Street Address

City

State

Zip Code

City

Area Code / Phone Number

Area Code / Phone Number

Email Address

Email Address

State

Zip Code

Certification
I certify that the information contained in this application has been
examined carefully by me and is true, correct, and complete, and
is current as of the date of this submission to the best of my
knowledge and belief. 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 also certify, with respect to any information pertaining to an
individual and submitted to the Board of Governors of the Federal
Reserve System (“Board”) in (or in connection with) this
application, that the applicant has the authority, on behalf of the
individual, to provide such information to the Board and to consent
or to object to public release of such information. I certify that the
applicant and the involved individual consent to public release of
any such information, except to the extent set forth in a written
request by the applicant or the individual, submitted in accordance
with the Instructions to this form and the Board’s Rules Regarding

Signed this

day of

,
Month

Availability of Information (12 CFR Part 261), requesting
confidential treatment for the information.
I acknowledge that approval of this application is in the discretion
of the Board. Actions or communications, whether oral, written, or
electronic, by the Board or its employees in connection with this
filing, including approval if granted, do not constitute a contract,
either express or implied, or any other obligation binding upon the
agency, the United States or any other entity of the United States,
or any officer or employee of the United States. Such actions or
communications will not affect the ability of the Board to exercise
its supervisory, regulatory, or examination powers under applicable
laws and regulations. I further acknowledge that the foregoing may
not be waived or modified by any employee or agency of the Board
or of the United States.

.
Year

Signature of Chief Executive Officer or Designee

Print or Type Name

Title

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