Reporting FR 2081c

Board of Governors of the Federal Reserve System OMB Number 7100-0134 Approval expires May 31, 2021
Federal Deposit Insurance Corporation
OMB Number 3064-0006 Approval expires June 30, 2021
Office of the Comptroller of the Currency
OMB Number 1557-0014 Approval expires February 28, 2021
Page 1 of 18

Board of Governors of the Federal Reserve System

Interagency Biographical and Financial Report—FR 2081c
An organization or a person is not required to respond to a collection of information unless it displays a currently valid OMB control
number.

General Information and Instructions
This Interagency Biographical and Financial Report (report) is
used by individuals1 in conjunction with other corporate filings to
the appropriate federal banking agency. This report is not a standalone document.

Preparation
Use of this report format is not mandatory. If an alternative format
is used, it must provide all requested information, including the
certification. 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" or "yes" should be explained.

In addition, each appropriate federal banking agency specifically
reserves the right to require up to five years of financial data
from any individual as well as the filing of additional information
or statements, such as a federal income tax return or a current
appraisal to support an asset's value.
If you have been convicted of any criminal offense involving dishonesty, breach of trust, or money laundering, or have agreed to
enter into a pretrial diversion or similar program in connection
with a prosecution of such offense (12 U.S.C. § 1829), you must
obtain approval from the FDIC before you can own, control, participate in the affairs of, or become an institution-affiliated party
of a depository institution.

DRAFT

The questions are not intended to limit the presentation nor are the
questions intended to duplicate information supplied on another
form or in an exhibit. For example, a cross-reference to the information is acceptable. Any cross-reference must be made to a specific
cite or location in the documents, so the information can be located
easily. Use additional sheets as necessary. Each federal banking
agency will provide additional instructions for use and preparation. If
the report is not complete, the federal banking agency may either
request additional information or return the filing. If you are a foreign
national or a United States citizen who currently resides in a foreign
country, additional information may be necessary.
Financial statements from individuals must have "as of" dates of
not more than 90 days prior to the date the financial report is submitted. All amounts in this report must be based on current
market value in United States dollars2 and agree with any totals
in the supplementary schedules. In addition to the sample financial schedules, you may wish to provide supplementary schedules for other items on the financial statement. If the sample
financial statement is used, an answer is required to each item. If
you submit an alternative Financial Report format, the information
must respond to each request for information contained in the
sample Financial Report.

Each individual must report promptly any material change in
the biographical report or financial condition that occurs during
the review period for the filing. For additional information regarding the processing procedures and guidelines, and any supplemental information that may be required, refer to the appropriate federal banking agency's procedural guidelines (for example, the OCC's Rules and Regulations (12 C.F.R Part 5), the
Comptroller's Licensing Manual, the FDIC's Rules and
Regulations (12 C.F.R. Part 303), the Board's Regulations Y and
LL (12 C.F.R. Part 225 and 12 C.F.R. Part 238, respectively),
and relevant policy statements), contact the agency directly for
specific instruction, or visit its website at www.occ.treas.gov,
www.fdic.gov, or www.federalreserve.gov.

Definitions
For purposes of this document:
Affiliate means any company that owns or controls, is owned or
controlled by, or is under common ownership or control with a
depository institution or depository institution holding company.

1. A company seeking to acquire direct or indirect control of a bank or savings association should consult with the appropriate federal banking agency
for filing instructions.
2. Provide the foreign currency exchange rate and conversion date, if applicable.

Public reporting burden for this collection of information is estimated to average 2.5 hours for biographical information and 2 hours for financial 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: Paperwork Reduction Act, Legal Division, Federal Deposit Insurance Corporation, 550 17th Street, NW,
Washington, DC 20429; Secretary, Board of Governors of the Federal Reserve System, 20th and C Streets, NW, Washington, DC 20551; or Licensing Activities Division, Office of the
Comptroller of the Currency, 400 7th Street, SW, Washington, DC 20219; and to the Office of Management and Budget, Paperwork Reduction Project, Washington, DC 20503.

06/2018

FR 2081c
Page 2 of 18

General Information and Instructions
—Continued
Associated means associated as an officer, director, organizer,
partner, trustee, or principal shareholder or owner.
Company means any corporation, association, partnership, limited liability company, business trust, sole proprietorship, joint
venture, or other similar organization.
Depository institution means any bank (including a national,
state, district, or foreign bank), savings association, savings
bank, savings and loan association, building and loan association, homestead association, cooperative bank, trust company,
industrial bank or loan company, or credit union. A United States
office, including a branch or agency, of a foreign bank is a
depository institution.
Management official includes a senior executive officer; director;
advisory or honorary director of a depository institution with total
assets of $100 million or more; branch manager; trustee of a
depository organization under the control of trustees; and any
person who has a representative or nominee serving in any of
those capacities.
Principal shareholder or owner means a person who directly or
indirectly owns, controls, or holds (either individually or as a
member of a group) the power to vote 10 percent or more of any
class of voting securities or other voting equity interest of the entity.

Confidentiality
Any individual desiring confidential treatment of specific portions
of the report must submit a request in writing with the report. The
request must discuss the justification for the requested treatment. The individual'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 under the Freedom of Information
Act (5 U.S.C. § 552). Information for which confidential treatment
is requested should be: (1) specifically identified in the public
portion of the report (by reference to the confidential section); (2)
separately bound; and (3) labeled "Confidential." The individual
should follow the same procedure for a request for confidential
treatment for the subsequent filing of supplemental information to
the report.
The individual should contact the appropriate federal banking agency for specific instructions regarding requests for
confidential treatment. The agency will determine whether
the information will be treated as confidential and will advise
the individual of any decision to make available to the public
information labeled "Confidential."

DRAFT

06/2018

FR 2081c
Page 3 of 18

Privacy Act Statement
Purposes
This form is used by certain shareholders, directors, and
executive officers, in conjunction with other filings to the
appropriate federal banking agency. The Federal banking
agencies are respectively the Board of Governors of the Federal
Reserve System (Board), the Office of the Comptroller of the
Currency (OCC), and the Federal Deposit Insurance Corporation
(FDIC). This Privacy Act statement is made pursuant to the
requirements of the Privacy Act of 1974, 5. U.S.C. § 552a.
Authority
The solicitation and collection of this information, including a
Social Security Number, is authorized by those statutes that
require an appropriate federal banking agency to determine the
competence, experience, integrity, and financial ability of
individuals proposing to serve a federally regulated financial
institution in an official capacity- that is, as a director, officer,
employee, or principal shareholder. These statutes include:
12 U.S.C. § 27 (national bank charters); 12 U.S.C. § 1464
(federal savings bank charters); 12 U.S.C. § 1815 (federal
deposit insurance); 12 U.S.C. § 1817(j)) (changes in control of
insured depository institutions); and 12 U.S.C. § 1831(i) (agency
disapproval of directors and senior executive officers of insured
depository institutions or depository institution holding companies).

2. To a federal agency in the executive, legislative, or judicial
branch of government, or to a Federal Reserve Bank, in connection with the hiring, retaining, or assigning of an employee,
the issuance of a security clearance, the conducting of a
security or suitability investigation of an individual, the classifying of jobs, the letting of a contract, the issuance of a
license, grant, or other benefits by the receiving entity, or the
lawful statutory, administrative, or investigative purpose of the
receiving entity to the extent that the information is relevant
and necessary to the receiving entity's decision on the matter;
3. To a congressional office in response to an inquiry made by
the congressional office at the request of the individual to
whom the record pertains;
4. To the Department of Justice (DOJ), a court, an adjudicative
body or administrative tribunal, a party in litigation, or a witness if the Board (or in the case of an OIG system, the OIG)
determines, in its sole discretion, that the information is relevant and necessary to the matter;
5. To contractors, agents, or others performing work on a contract, service, cooperative agreement, job, or other activity for
the Board and who have a need to access the information in
the performance of their duties or activities for the Board;

DRAFT

INFORMATION REGARDING DISCLOSURE OF YOUR SOCIAL
SECURITY NUMBER UNDER PUBLIC LAW 93-579 SECTION 7
(B), IF APPLICABLE
Disclosure by you of your Social Security Number is optional to obtain
the services, benefits, or processes that you are seeking. The Social
Security Number provided may be used to conduct a background
check on the individual in order to evaluate the competence,
experience, integrity, and financial ability of individuals proposing to
serve a federally regulated financial institution in an official capacity.
Effects of Nondisclosure
Provision of the requested information, including Social Security
Number, is voluntary. However, the failure to provide any requested
information may result in the denial, disapproval, or delay in the
processing of an application or notice.
Routine Uses for Board Filers
The information you provide will be stored by the Board in the
System of Records entitled “BGFRS-37: Electronic Applications.”
All or part of the information may be disclosed outside of the
Board as follows:

1. To the appropriate federal, state, local, foreign, or self-regulatory
organization or agency responsible for investigating, prosecuting,
enforcing, implementing, issuing, or carrying out a statute, rule,
regulation, order, policy, or license if the information may be
relevant to a potential violation of civil or criminal law, rule, regulation, order, policy, or license;

6. To appropriate agencies, entities, and persons when (1) the
Board suspects or confirms that the security or confidentiality
of information in the system of records has been compromised; (2) the Board has determined that as a result of the
suspected or confirmed compromise there is a risk of harm to
economic or property interest, identity theft or fraud, or harm
to the security or integrity of this system or other systems or
programs (whether maintained by the Board or another
agency or entity) that rely upon the compromised information;
and (3) the disclosure is made to such agencies, entities, and
persons who are reasonably necessary to assist in connection with the Board's efforts to respond to the suspected or
confirmed compromise and prevent, minimize, or remedy
such harm;
7. To other bank and thrift regulatory agencies pursuant to
explicit information sharing agreements for regulatory comment purposes; and

8. To another federal agency or federal entity, when the Board
determines that the information from the system of records is
reasonably necessary to assist the recipient agency or entity
in (1) responding to a suspected or confirmed breach, or (2)
preventing, minimizing, or remedying the risk of harm to
individuals, the recipient agency or entity (including its
information systems, programs, and operations), the Federal
Government, or national security, resulting from a suspected
or confirmed breach.

10/2019

FR 2081c
Page 4 of 18

Privacy Act Statement–Continued
Routine Uses for FDIC Filers
The information you provide will be stored by the FDIC in the
System of Records entitled “FDIC 3064-0002: Financial
Institution Investigative and Enforcement Records.” All or part of
the information may be disclosed outside of the FDIC as follows:
1. To federal, state, local, foreign, or self-regulatory authorities
responsible for investigating or prosecuting a violation of, or for
enforcing or implementing a statute, rule, regulation, or order
issued, when the information indicates a violation or potential
violation of law, whether civil, criminal, or regulatory in nature,
and whether arising by general statute or particular program
statute, or by regulation, rule, or order issued pursuant thereto;
2. To a court, magistrate, or other administrative body in the
course of presenting evidence, including disclosures to counsel or witnesses in the course of civil discovery, litigation, or
settlement negotiations or in connection with criminal proceedings, when the FDIC is a party to the proceeding or has a
significant interest in the proceeding, to the extent that the
information is determined to be relevant and necessary;
3. To a congressional office in response to an inquiry made by
the congressional office at the request of the individual who is
the subject of the record;

9. To a financial institution affected by enforcement activities or
reported criminal activities.
Routine Uses for OCC Filers
The information you provide on this form, if the form is submitted
in connection with a notice of proposed change in employee, officer or director, may be stored by the OCC in the System of
Records entitled “Notice of Proposed Changes in Employees,
Officers and Directors Tracking System.” Information maintained
in this system may be disclosed to:
1. A Section 5.51 entity, a Section 5.20(g)(2) entity, a part 163,
subpart H entity, or a Section 1818(b) entity in connection with
review and action on a notice filed by that entity;
2. Third parties to the extent necessary to obtain information that
is pertinent to the OCC's review and action on a notice
received under any authority cited herein;
3. Appropriate governmental or self-regulatory organizations
when the OCC determines that the records are relevant and
necessary to the governmental or self-regulatory organization's regulation or supervision of financial service providers,
including the review of the qualifications and fitness of individuals who are or propose to become responsible for the business operations of such providers;

DRAFT

4. To appropriate agencies, entities, and persons when (1) FDIC
suspects or has confirmed that there has been a breach of the
system of records; (2) FDIC has determined that as a result of
the suspected or confirmed breach there is a risk of harm to
individuals, FDIC (including its information systems, programs, and operations), the federal government, or national
security; and (3) the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with FDIC's efforts to respond to the suspected or confirmed breach or to prevent, minimize, or remedy such harm;
5. To another federal agency or federal entity, when FDIC determines that information from this system of records is reasonably necessary to assist the recipient agency or entity in (1)
responding to a suspected or confirmed breach or (2) preventing, minimizing, or remedying the risk of harm to individuals,
the recipient agency or entity (including its information systems, programs, and operations), the federal government, or
national security, resulting from a suspected or confirmed
breach;

6. To federal, state, or foreign authorities in connection with hiring
or retaining an individual, conducting a background security or
suitability investigation, adjudication of liability, or eligibility for
a license, contract, grant, or other benefit;
7. To contractors, grantees, volunteers, and others performing or
working on a contract, service, grant, cooperative agreement,
or project for the FDIC, the OIG, or the federal government for
use in carrying out their obligations under such contract,
grant, agreement or project;
8. To federal, state or foreign financial institutions supervisory
authorities for regulatory or enforcement purposes; and

4. An appropriate governmental, tribal, self-regulatory, or professional organization if the information is relevant to a known or
suspected violation of a law or licensing standard within that
organization's jurisdiction;
5. The Department of Justice (DOJ), a court, an adjudicative
body, a party in litigation, or a witness if the OCC determines
that the information is relevant and necessary to a proceeding
in which the OCC, any OCC employee in his or her official
capacity, any OCC employee in his or her individual capacity
represented by the DOJ or the OCC, or the United States is a
party or has an interest;
6. A congressional office when the information is relevant to an
inquiry made at the request of the individual about whom the
record is maintained;
7. A contractor or agent who needs to have access to this
system of records to perform an assigned activity;
8. Third parties when mandated or authorized by statute; or
9. Appropriate agencies, entities, and persons when: (a) The
DOJ suspects or has confirmed that the security or confidentiality of information in the system of records has been compromised; (b) the DOJ 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 DOJ 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 DOJ's
efforts to respond to the suspected or confirmed compromise
and prevent, minimize, or remedy such harm.

10/2019

FR 2081c
Page 5 of 18

This is filed with respect to:
Name of Subject Institution or Holding Company

City, State

Type of Filing (check all that apply)

Position (check all that apply)

Bank or Savings Association Charter
Bank or Savings and Loan Holding Company
Change in Bank Control1
Change in Senior Executive Officer or Director
Citizenship Waiver
Charter Conversion
Deposit Insurance
Federal Branch or Agency
Other

Organizer
Director
Senior Executive Officer
Principal Shareholder
Trustee
Manager
Other

Biographical Report
1. Personal Information
a. Name
Last

First

b. Residence

Middle (Full Name)

DRAFT

Street Address

City / Town

State / Province

ZIP / Postal Code

Country

c. If at residence less than five years, list addresses and dates occupied for past five years.

Date From

Date To

Number and Street

City

State / Prov.

ZIP / Postal Code

Country

Date From

Date To

Number and Street

City

State / Prov.

ZIP / Postal Code

Country

Date From

Date To

Number and Street

City

State / Prov.

ZIP / Postal Code

Country

Date From

Date To

Number and Street

City

State / Prov.

ZIP / Postal Code

Country

Date From

Date To

Number and Street

City

State / Prov.

ZIP / Postal Code

Country

d. Date of Birth
Month / Day / Year

e. Place of Birth
City

State / Province

Country

f. United States Social Security Number

06/2018

FR 2081c
Page 6 of 18

g. Are you a United States citizen?

Yes

No
Date, if Naturalized

h. If not a United States citizen, or you have dual citizenship, provide:
Country of Citizenship
Passport Number
Home Country Identification Number
Immigration File Number
Father's Full Name

Expiration Date

Mother's Full Name, including maiden name
i. Telephone numbers where you may be reached during business hours and an e-mail address:
Area Code, Telephone Number, including Country Code if outside U.S.
E-mail Address

j. List other names you used and the period of time you used them (for example, your maiden name, name by a former marriage,
former name, alias, or nickname). If the other name is your maiden name, put "nee" in front of it.
Period of Time Used
Other Names Used

2. Employment Record

Beginning Date

DRAFT

Ending Date

a. List employment in reverse chronological order for the last five years. Provide the following information. (If the applicant has
additional relevant employment experience, or additional information to support the application, provide an attachment).
Beginning Date

Ending Date

Employer's Name

Nature of Business

Street

City

Title or Position

State / Prov.

Nature of Duties

Reason for Leaving

Beginning Date

Ending Date

Employer's Name
Nature of Business

Street

City

Title or Position

State / Prov.
Nature of Duties

Reason for Leaving

Beginning Date

Ending Date

Employer's Name
Nature of Business

Street
Title or Position

City

State / Prov.
Nature of Duties

Reason for Leaving

b. Have you ever been dismissed or asked to resign from any past employment, including a less than honorable discharge from
military service?
Yes
No
If "Yes," provide the following information:
Employer's Name
Title or Position

Street

City
Date of Discharge

State / Prov. Area Code / Phone Number

Explanation

12/2020

FR 2081c
Page 7 of 18

3. Education and Professional Credentials
a. List each diploma or degree from high schools, colleges, universities, or other schools.
School's Name

Address

Date From

Date To

Degree

School's Name

Address

Date From

Date To

Degree

School's Name

Address

Date From

Date To

Degree

b. List each professional license or similar certificate you now hold or have held (for example, Attorney, Physician, CPA, NASD or
SEC registration).
License

Issuing Authority

Date Issued

Status

Expiration

License

Issuing Authority

Date Issued

Status

Expiration

License

Issuing Authority

Date Issued

Status

Expiration

4. Business and Banking Affiliations
a. List any company with which you are Associated and provide the following information:

Company Name

DRAFT
Address

Nature or Type of Business

Position Held or Relationship to the Company

Company Name

Address

%

Ownership Percentage

Address

Start Date

Nature or Type of Business

Position Held or Relationship to the Company
Company Name

Start Date

Nature or Type of Business

Position Held or Relationship to the Company

Company Name

%

Ownership Percentage

%

Ownership Percentage
Address

Start Date

Nature or Type of Business
%

Position Held or Relationship to the Company

Ownership Percentage

Start Date

b. List the name of any depository institution or depository institution holding company with which you are or were Associated and
provide the following information:

Depository Institution/Holding Company Name

Address

Nature of Banking Activity
%

Position Held or Relationship
Depository Institution/Holding Company Name

Ownership Percentage
Address

Start Date

End Date

Nature of Banking Activity
%

Position Held or Relationship
Depository Institution/Holding Company Name

Ownership Percentage
Address

Start Date

End Date

Nature of Banking Activity
%

Position Held or Relationship
Depository Institution/Holding Company Name

Ownership Percentage
Address

Start Date

End Date

Nature of Banking Activity
%

Position Held or Relationship

Ownership Percentage

Start Date

End Date
06/2018

FR 2081c
Page 8 of 18

c. Are you in the process of being considered for a Management official position at another depository institution or depository
institution holding company?
Yes
No
If "Yes," provide the name of the depository institution or depository institution holding company and the position. If an application
has been submitted for regulatory review, provide the name of the federal banking agency.

Depository Institution / Holding Company Name

Position

Appropriate Federal Banking Agency

Position

d. Are you now or are you proposed to be a "Management official" of another insured depository institution or depository institution
holding company?
Yes
No
If "Yes," explain either why the potential interlock is not a violation of the Depository Institution Management Interlocks Act
(12 U.S.C. §§ 3201-3208) or what action will be taken to prevent a violation.

5. Legal and Related Matters (If you answer "Yes" to any question, see also question 5.g.)

DRAFT

a. Have you been involved in any of the following filings where the filing was denied, disapproved, withdrawn, or otherwise
returned without favorable action by a federal or state regulatory authority or a self-regulatory organization:
(1) A charter or license application, a depository institution holding company application, or a federal deposit insurance application, in which you were listed as an organizer, director, senior executive officer, or a person that would own or control (either
individually or as a member of a group) 10 percent or more of any class of voting securities or other voting equity interest of
the institution, or similar position?
Yes
No
(2) A merger application in which you were listed as a director, senior executive officer, or similar position?

Yes

No

(3) A notice of change in director or senior executive officer, or similar form, in which you were listed as a director, senior executive officer, or similar position?
Yes
No
(4) A notice of change in control for a depository institution or other company, or a similar form, in which you were listed (either
individually or as a member of a group) as an acquirer or transferee?
Yes
No
(5) Any other application, notice, or other regulatory or administrative request which was filed with a federal or state regulatory
authority or a self-regulatory organization in which you were listed in some capacity?
Yes
No
b. Have you or any depository institution or depository institution holding company with which you are or were Associated been
subject to any supervisory agreement, enforcement action, civil money penalty, prohibition or removal order, or other supervisory or administrative action taken or imposed by any federal or state regulatory authority or other governmental entity?
Yes
No
c. Has any depository institution with which you are or were Associated:
(1) Been placed into conservatorship or receivership or otherwise failed?

Yes

No

(2) Received financial assistance from a federal agency or instrumentality (for example, FDIC, Resolution Trust Corporation,
Federal Savings and Loan Insurance Corporation)?
Yes
No
(3) Merged with or been acquired by an institution that received financial assistance from a federal agency or instrumentality in
Yes
No
connection with the transaction?

06/2018

FR 2081c
Page 9 of 18

d. Have you or any company with which you are or were Associated:
(1) Filed a petition under any chapter of the Bankruptcy Code or had an involuntary bankruptcy petition filed against you or the
Yes
No
company?
(2) Defaulted on a loan or financial obligation of any sort, whether as obligor, cosigner, or guarantor?

Yes

No

(3) Forfeited property in full or partial satisfaction of any financial obligation?

Yes

No

(4) Had a lien placed against property for failure to pay taxes or other debts?

Yes

No

Yes

No

(5) Had wages or income garnished for any reason?

Yes

No

(6) Failed or refused to pay any outstanding judgments?

Yes

No

(7) Failed to satisfy any federal, state or local tax obligations?

e. Have you or any company or depository institution with which you are or were Associated been involved in any criminal or civil
lawsuit, formal or informal investigation, examination, or administrative proceeding that may result in, or resulted in, any penalty
(including, but not limited to, any sanction, fine, order to pay damages, loss of right or benefit, forfeiture of property interest, suspension, removal, disbarment, or revocation of license), agreement (including a deferred prosecution agreement, consent order,
written agreement or memorandum of understanding, undertaking, consent, judgment, or order imposed by or entered into with
any of the following entities:
(1) Any state, federal, or foreign court?

Yes

No

(2) Any department, agency, or commission of the United States government?
(3) Any state, municipal, or foreign governmental entity?

Yes

No

Yes

No

No

DRAFT

(4) Any self-regulatory organization (for example, NASD, FASB, state bar)?

Yes

f. Have you or any company or depository institution with which you are or were Associated ever been arrested for, charged with,
indicted for, or convicted of, or ever pleaded nolo contendere to, any criminal matter (including, but not limited to, driving under
the influence, reckless driving, and disorderly conduct)?
Yes
No
g. If you answer "Yes" to any question in 5(a) through 5(f), provide your explanation by identifying the number of the question,
describing the situation in detail (providing supplemental documentation as appropriate), and, where relevant, including the:

•
•
•
•
•
•
•
•
•
•

Date of any relevant event.
Name of any regulatory agency, or self-regulatory organization involved.
Name and location of any institution, company or party involved.
Nature of your association with any institution or company (for example, officer, director, organizer, principal shareholder,
or owner).
Type of any application, notice, or other regulatory or administrative request.
Nature of any supervisory, enforcement or administrative action.
Direct and indirect debt terms, defaulted amount, and creditor regarding any financial obligation.
Nature of any lawsuit, charge, or proceeding, conviction, or finding.
Jurisdiction and court in which any legal proceeding occurred.
Resolution or disposition of the matter.

For any of the matters noted above, indicate whether any insured depository institution suffered a loss as a result. If so, identify
the insured depository institution and the amount of the loss, and indicate whether the institution was ever made whole.

06/2018

FR 2081c
Page 10 of 18

6. Additional Information
Present any other information you believe is important to evaluate your filing. If you are involved in the organization of a new depository institution or depository institution holding company, discuss your specific role.

DRAFT

06/2018

FR 2081c
Page 11 of 18

Financial Report
Financial Statement as of
Month / Year

Assets

Liabilities* and Net Worth

Cash on hand and in depository institutions

$

$

Accounts payable

Marketable securities (Schedule A)

Notes payable and other loans (Schedule F)

Notes receivable (Schedule B)

Real estate mortgages (Schedule C)

Real estate
(Schedule C, current market value)

Other liabilities (Schedule G)
Total Liabilities

Proprietary interests and other securities
(Schedule D)
Retirement funds and other assets
(Schedule E)
Total Assets $

Net worth
(Total assets less total liabilities)

Total Liabilities and Net Worth $

DRAFT

* For any debt reported on any of the supporting schedules, indicate any liability that is contractually delinquent and provide a discussion on how the
delinquency will be resolved.

06/2018

FR 2081c
Page 12 of 18

Contingent Liabilities
In addition to the liabilities listed on the Financial Statement, have you endorsed, guaranteed, or become otherwise indirectly or
Yes
No
contingently liable for the debts of others or through a pending lawsuit?
If "Yes," complete the following:

Debtor or Obligor

Creditor or Obligee

Name

Name

Address

Address

Name

Name

Address

Address

Name

Name

Description and Value of Collateral

Current Amount

Date Due

$

Address

Name

Address

DRAFT
Address

Name

Address

Total $

06/2018

FR 2081c
Page 13 of 18

Supporting Schedules
Schedules must agree in total with the appropriate item contained in the Financial Statement on page 11
of this report.

Schedule A—Marketable Securities
Indicate all debt and equity securities listed on an exchange or otherwise regularly traded in an open market. Separate debt and equity
securities. Securities of closely held corporations should be listed on Schedule D—Proprietary Interests. The description should include
the name of the issuer, the principal amount or number of shares held, and the interest rate, if applicable. Small holdings may be aggregated and shown as "other" provided that they account for no more than 10 percent of marketable securities.
Description

Market Value
$

DRAFT

Total $

Schedule B—Notes Receivable

The description should include the name of the obligor, the note's maturity and terms of repayment, and a description of any collateral.
If the note is payable to you and others jointly, indicate only your beneficial interest under Current Balance.
Description

Current Balance
$

Total $

06/2018

FR 2081c
Page 14 of 18

Schedule C—Real Estate and Related Loans
List all real estate in which you hold a beneficial interest. Submit year-end financial statements, including profit and loss statements, for
the last two years for each investment (exclude residence) in which you have an interest equal to 10 percent or more of your net worth.
Also submit a cash flow statement on any investment property valued at 10 percent or more of net worth.

Description and Address
of Property

Owner of
Property

Percent
Ownership

Mortgage
Holder

Current
Mortgage
Balance1

Maturity
Date

Current
Market
Value2

$

$

Total $

$

%
%
%
%
%

1. Carry Total forward to Liabilities—Real estate mortgages
2. Carry Total forward to Assets—Real estate

DRAFT

Schedule D—Proprietary Interests and Other Securities

List all companies, the shares of which are not listed on a securities exchange or otherwise regularly traded, in which you hold a beneficial interest. (Submit year-end financial statements, including profit and loss and cash flow statements, for the last two years for each
business interest in which you have an interest equal to 10 percent or more of your net worth.)
Name and Address
of Company

Legal Form
of Company

Nature of Business

Percent
Ownership

Current Value
% $
%
%
%

Total $

06/2018

FR 2081c
Page 15 of 18

Schedule E—Other Assets
Include retirement funds (for example, 401K, IRA, Keogh), accounts receivable, merchandise and inventory at lower of cost or market
value, machinery and equipment (less depreciation), and life insurance at its cash surrender value.
Description

Basis for Valuation

Current Value
$

Total

$

DRAFT

06/2018

FR 2081c
Page 16 of 18

Schedule F—Notes Payable and Other Loans
Indicate all loans or notes payable, including loans on life insurance and retirement funds (but not real estate mortgages listed in
Schedule C). Loan origination information must include the original date, loan amount, and co-makers, if any, and their percent obligation. Small obligations may be aggregated and shown as "other," provided that they account for no more than 20 percent of other loans
and notes payable. Indicate any debt that is contractually delinquent by an asterisk next to the current balance.
Name and Address of Creditor
and Loan Origination Information

Description and Value of
Collateral

Maturity Date

Current Balance
$

Total $

Schedule G—Other Liabilities
Include interest and taxes due and unpaid, other debts accrued, and other liabilities.
Payable To

DRAFT
Description

Maturity Date

Current Balance
$

Total $

06/2018

FR 2081c
Page 17 of 18

Cash Flow Statement1
Year

Projected Current
Year

Year

Projected Next
Year

Sources of Cash
Salaries, wages, commissions,
and other employment income

$

$

$

$

Rents, royalties,
and investments
Income from dividends
and interest
Income and other distributions
from partnerships
Other sources2
Total cash received
Uses of Cash
Personal living expenses
(rent, household)
Fixed obligations3
Income taxes
Capital contributions
to partnerships
Other uses2
Total cash outlay
Net Cash Flow (deficit)

DRAFT
$

$

$

$

1. Discuss any significant changes from one year to the next on a separate page.
2. Itemize on a separate page any items amounting to 10 percent or more of total cash received or total cash outlay.
3. Fixed obligations include debt service on all loans and any budgeted capital improvement expenditures for real estate investments.
Any loan proceeds or debt service related to this transaction should be included in projections for other sources or uses.

06/2018

FR 2081c
Page 18 of 18

Certifications
Biographical and Financial Report Certification (Individual Applicant)
I understand that the appropriate federal banking agency may conduct extensive checks into my background, experience, and related
matters in conjunction with my application or filing. I certify that the information contained in the biographical report and financial report,
including all attachments, has been carefully examined by me and is true, correct, and complete. 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.
Signed this

day of
Day

,

.
Year

Month

Signature

Signature1

Print or Type Name

Print or Type Name

Title (if applicable)

Title (if applicable)

Financial Report Certification (If filing joint financial statements, Individual Applicant's spouse must complete
the following certification.)
I understand that the appropriate federal banking agency may conduct extensive background checks in conjunction with the information
contained in the joint financial report. I certify that the information contained in the joint financial report, including all attachments, has
been carefully examined by me and is true, correct, and complete. 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.
Signed this

Signature
Print or Type Name
Title (if applicable)

DRAFT

day of
Day

,

Month

.

Year

Signature1

Print or Type Name
Title (if applicable)

1. If a joint financial statement is being submitted, both parties should complete the "Certification."

06/2018