Notice of Proposed Declaration of Dividend

FR 1583
OMB Number 7100-0339
Approval expires TBD
Page 1 of 1

Board of Governors of the Federal Reserve System

Notice of Proposed Declaration of Dividend—FR 1583

This form is used to acquire information concerning the amount
of capital that an institution intends to distribute, pursuant to
Section 10(f) of the Home Owners’ Loan Act (12 U.S.C § 1467a(f))
and 12 CFR § 238, subpart K (Regulation LL).

Date of Filing:

The Federal Reserve may not conduct or sponsor, and an
organization (or a person) is not required to respond to, a
collection of information unless it displays a currently valid
OMB control number.

_______________________

We, the undersigned executive officer and secretary, pursuant to the resolution of majority of the members of the
board directors, of:

____________________________________________________
Savings Association Name

____________________________________________________
Street Address of Savings Association

__________________________________ ________________

________________

City

Zip Code

State

(hereinafter the Institution), hereby provide notice to the Federal Reserve Board that the Institution intends to
declare a ____________________________ dividend (as that term is defined in 12 CFR § 238.102) in the amount of
Nature of the Dividend (e.g., cash, stock)

$___________________, pursuant to 12 CFR § 238.103.
We are aware that the Federal Reserve Board may request additional information or may impose conditions for the
dividend and may determine that such dividend does not comply with the requirements of 12 CFR Part 238, subpart K.

______________________________________________
Printed Name of Executive Officer

______________________________________________
Signature of Executive Officer

______________________________________________
Printed Name of Secretary

______________________________________________
Signature of Secretary

Date of Receipt by Federal Reserve Bank:

________________________

Savings associations must maintain in their files a manually signed and attested printout of the data submitted.
Public reporting burden for this information collection is estimated to average 16.5 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, formatting the information, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this information collection, 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 (7100–0339), Washington, DC 20503.
mm/yyyy