Application and Related Forms

OMB Control #3170-0037
Expiration Date: XX/XX/XXXX

FINANCIAL DISCLOSURE
Part I: Assets and Income
Please list the following types of Assets and Income in the boxes provided below for yourself, your
spouse and any dependent children.
Assets held for investment with a value greater than $1,000 as of the date you sign this form OR assets held
for investment that produced more than $200 in income during the 12-month period prior to the date you
sign this form. Such assets include:
 Stocks, bonds, annuities, trust holdings, partnership interests, life insurance, investment real
estate, or a privately-held trade or business
 Sector mutual funds: those funds invested in a particular industry, business, or location such as ABC
Electronics Fund or XYZ Canada Fund (report the full name of the fund, not just the general family
fund name)
 Holdings of retirement plans, such as 401(k)s or IRAs
o (list each holding except diversified mutual funds)
 Holdings of investment life insurance
 Holdings of variable annuities
 Defined benefit pension plans provided by a former employer (include the name of the employer)
You may distinguish any entry for a family member by preceding it with S for spouse, DC for dependent
child, or J for jointly held.
Definitions
Diversified Mutual Fund – A mutual fund that does not have a stated policy of concentrating its
investments in one industry, business, or single country other than the United States.
Sector Mutual Fund – A mutual fund that concentrates its investments in an industry, business,
single country other than the United States, or bonds of a single state within the United States.
Dependent Child – A son, daughter, stepson or stepdaughter who is either unmarried and under
age 21 and living in the filer’s house, or considered dependent under the U.S. tax code.
Specific stock, bond, sector mutual fund, type/location of real estate, etc. (Indicate the full
name of each specific asset or investment. You may add the ticker symbol to the full name.
Asset value is not required.)
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APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

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OMB Control #3170-0037
Expiration Date: xx/xx/xxxx
Privacy Act Statement
The information that you provide will be used by the Consumer Financial Protection Bureau (CFPB) to
determine qualifications, suitability, and availability for service on advisory boards, bodies, panels,
committees or other similar groups. The information will be used to conduct background clearances
and/or for annual reports on advisory boards, bodies, panels, committees or other similar groups. The
information will be used by and disclosed to employees, contractors, agents, and others authorized by
the CFPB to receive this information to assist in related activities. The information may also be
disclosed to:
Appropriate agencies, entities, and persons when: (a) the CFPB suspects or has confirmed that the
security or confidentiality of information in the system of records has been compromised; (b) the CFPB
has determined that, as a result of the suspected or confirmed compromise, there is a risk of harm to
economic or property interests, identity theft or fraud, or harm to the security or integrity of this system
or other systems or programs (whether maintained by the CFPB or another agency or entity) that rely
upon the compromised information; and (c) the disclosure made to such agencies, entities, and
persons is reasonably necessary to assist in connection with the CFPB’s efforts to respond to the
suspected or confirmed compromise and prevent, minimize, or remedy such harm;
Another federal or state agency to (a) permit a decision as to access, amendment or correction of
records to be made in consultation with or by that agency, or (b) verify the identity of an individual or
the accuracy of information submitted by an individual who has requested access to or amendment or
correction of records;
To the Office of the President in response to an inquiry from that office made at the request of the
subject of a record or a third party on that person’s behalf;
Congressional offices in response to an inquiry made at the request of the individual to whom the
record pertains;
Contractors, agents, or other authorized individuals performing work on a contract, service,
cooperative agreement, job, or other activity on behalf of the CFPB or Federal Government and who
have a need to access the information in the performance of their duties or activities;
The U.S. Department of Justice (“DOJ”) for its use in providing legal advice to the CFPB or in
representing the CFPB in a proceeding before a court, adjudicative body, or other administrative body
before which the CFPB is authorized to appear, where the use of such information by the DOJ is
deemed by the CFPB to be relevant and necessary to the litigation, and such proceeding names as a
party or interests: (a) The CFPB; (b) Any employee of the CFPB in his or her official capacity; (c) Any
employee of the CFPB in his or her individual capacity where DOJ has agreed to represent the
employee; or (d) The United States, where the CFPB determines that litigation is likely to affect the
CFPB or any of its components;
To the public in the form of names, affiliations, and other pertinent biographical information of board or
committee members; and
Appropriate agencies, entities, and persons to the extent necessary to obtain information relevant to
making a determination of whether an individual is eligible to serve on a CFPB board or committee.
The collection of this information is authorized by Pub. L. No. 111-203, Title X, sections 1011, 1012,
1014, codified at 12 U.S.C. §§ 5491, 5492, 5494. Providing your identifying information is voluntary,
but not doing so may result in non-selection of a prospective advisory board, body, panel, committee,
or other similar group membership. However, failure to provide your Social Security number may not
be the reason for non-selection. The Bureau has a special interest in ensuring that women, minority
groups, and individuals with disabilities are adequately represented on the Board and Councils, and
therefore, encourages applications from qualified candidates from these groups. In furtherance of this
interest, the Bureau invites applicants to the Board and Councils to voluntarily self-identify their race or
ethnicity. Submission of this information is voluntary and refusal to provide it will not disqualify you
from consideration for service on the Board or Councils. The information obtained will be kept
confidential and will only be used for internal management purposes. There have been occasions
when members of the public and/or Congress have requested information regarding the demographic

OMB Control #3170-0037
Expiration Date: xx/xx/xxxx
composition of the Board and Councils. If the Bureau receives and responds to such a request, data
provided will not identify any specific individual.”

Paperwork Reduction Act
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless it displays a valid OMB control
number. The OMB control number for this collection is 3170-0037. It expires on XX/XX/XXXX. The
time required to complete this information collection is estimated to average approximately 10 minutes
per response. The obligation to respond to this collection of information is voluntary. Comments
regarding this collection of information, including the estimated response time, suggestions for
improving the usefulness of the information, or suggestions for reducing the burden to respond to this
collection should be submitted to Bureau at the Consumer Financial Protection Bureau (Attention: PRA
Office), 1700 G Street NW, Washington, DC 20552, or by email to [email protected].
The Bureau will not disclose any personally identifiable information collected except to the extent
that it is required to do so by law and as provided in the Privacy Act Statement listed above.
Additionally, the Bureau will treat the information collected consistent with its confidentiality regulations
at 12 C.F.R. Part 1070, et seq.
I certify that the statements I have made on this form and all attached statements are true,
complete, and correct to the best of my knowledge.
Print Name

Date (mm/dd/yy)

Signature

Date (mm/dd/yy)

APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

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