130-131-132 - Management Interlocks Application

OMB no. 1557-0014

Expiration date: See www.occ.gov

Management Interlock Application

General Information and Instructions

Preparation and Use

This application is used to seek an exemption from the prohibitions of the Depository Institution Management Interlocks Act (12 USC 3201–3208) and its implementing regulation, 12 CFR 26.6(a). This application may also be used to seek Office of the Comptroller of the Currency (OCC) approval for dual service at a diversified savings and loan holding company pursuant to 12 CFR 26.4(h).

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” should be explained.

The questions in the application are not intended to limit the applicant’s presentation nor are the questions intended to duplicate information supplied on another form or in an exhibit. For such information, a cross-reference to the information is acceptable. Any cross-reference must be made to a specific site or location in the documents, so the information can be found easily. Supporting information for all relevant factors, setting forth the basis for the applicant’s conclusions, should accompany the application. The regulatory agency may request additional information.

This application form collects information that the OCC will need to evaluate an exemption application. The OCC must consider the applicable statutory requirements set forth above, as well as applicable regulatory requirements, when acting on this application. For additional information regarding these statutory and regulatory requirements, as well as processing procedures and guidelines and any supplemental information that may be required, refer to the OCC’s procedural guidelines in the Comptroller’s Licensing Manual. The applicant may contact the OCC directly for specific instruction or visit the OCC’s Web site at www.occ.gov.

Submission

In addition to an original application and the appropriate number of signed copies, submit an electronic copy of the information in the application, especially of the business plan’s financial projections, if applicable. For e-mail submissions, contact the OCC for instructions and information about secure transmission of confidential material.

Confidentiality

Any applicant desiring confidential treatment of specific portions of the application must submit a request in writing with the application. The request must discuss the justification for the requested treatment. The applicant'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 (5 USC 552 or relevant state law). Information for which confidential treatment is requested should be (1) specifically identified in the public portion of the application (by reference to the confidential section); (2) separately bound; and (3) labeled “Confidential.” The applicant should follow the same procedure when requesting confidential treatment for the subsequent filing of supplemental information to the application. Contact the OCC for any further questions regarding requests for confidential treatment.

Management Interlock Application

Applicant

_____________________________________________________________________

Name Charter no.

_____________________________________________________________________

Current street address

_____________________________________________________________________

City County State Zip code

Parent Company Identifying Information (if applicable)

_____________________________________________________________________

Name

_____________________________________________________________________

Street

_____________________________________________________________________

City State Zip code

Contact Person

_____________________________________________________________________

Name Title

_____________________________________________________________________

Employer

_____________________________________________________________________

Street

_____________________________________________________________________

City State Zip code

_____________________________________________________________________

Telephone no. Fax no. E-mail address

1. Overview

• Name of management official

• Current title of management position

• Name and location of depository institution

• Proposed additional title of management position

• Proposed additional name and location of depository institution

Indicate if one of the following presumptions applies to the depository organization seeking to add the management official:

• Primarily serves low-and moderate-income areas?

• Is controlled or managed by persons who are members of a minority group, or women?

• Is a depository institution that has been chartered for less than two years?

• Is deemed to be in “troubled condition” as defined in 12 CFR 5.51(c)(6)?

If one of the above presumptions applies, explain why the interlock will not present safety and soundness concerns.

If none of the above presumptions apply, explain why the interlock will not result in a monopoly or substantial lessening of competition and would not present safety and soundness concerns.

2. Dual Service at a Diversified Savings and Loan Holding Company

Discuss whether the interlock will have an anti-competitive effect in financial services in any part of the Unites States.

Explain why the interlock will not lead to substantial conflicts of interest or unsafe or unsound practices.

3. Other Information

Enclose the following:

• A signed biographical portion of the Interagency Biographical and Financial Report.

• A discussion of the management official’s qualifications and experience.

• Where no presumption exists, market share information demonstrating that the interlock will not produce a monopoly or a substantial lessening of competition, including any expansion, merger, or growth plans.

OCC CERTIFICATION

I certify that the bank’s board of directors, shareholders or a designated official has authorized the filing of this application. I certify that the information contained in this application has been examined carefully and is true, correct, complete and current as of the date of this submission. Additionally, I agree to notify the OCC if the facts described in the filing materially change prior to receiving a decision or at any time prior to consummation of the action contemplated herein.

I acknowledge that any misrepresentation or omission of a material fact with respect to this application, any attachments to it, and any other documents or information provided in connection with this application may be grounds for denial of the application or revocation of its approval, and may subject the undersigned to legal sanctions, including the criminal sanctions provided for in Title 18 of the United States Code.

I acknowledge that the approval of this application is in the discretion of the OCC. The activities and communications by OCC employees in connection with the filing, including approval of the application if granted, do not constitute a contract, express or implied, or any other obligation binding upon the OCC, the United States, any agency or entity of the United States, or any officer or employee of the United States, and do not affect the ability of the OCC to exercise its supervisory, regulatory and examination authorities under applicable law and regulations. I further acknowledge that the foregoing may not be waived or modified by any employee or agent of the OCC or the United States.

_______________________________________

President or other authorized officer

_______________________________________

Typed name

_______________________________________

Title

_______________________________________

Employer

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