State Regulatory Response Form

OMB Control Number: 1505-0267

OMB Expiration Date: 09/30/2021

ECIP – Form for Submission of Views by State Banking Regulators

This form should be completed and uploaded to Treasury’s database no later than [30] days after being notified by Treasury of a submitted application.

1. ECIP Applicant Information

Applicant Name:	[Text]
Applicant ECIP ID Number:	[Text]
Applicant ECIP Investment Request Amount ($):	[$]

Below, please provide the name and requested identification of the depository institution for which your agency is submitting views. This may be a different institution than the ECIP applicant, for example, where the ECIP applicant is the holding company of the depository institution supervised by your agency.

Institution Name:	[Text]
RSSD #::	[Text]
FDIC Cert Number (if applicable):	[Text]

2. Agency Information

State Agency:	[Text]
Contact Name:	[Text]
Title:	[Text]
Phone:	[Text]
Email:	[Text]
Date Prepared:	[Text]

Please provide any information that your agency would like to submit within 30-calendar days after receiving notice from Treasury that an application is available for review. The prompts in this form pertain to the depository institution supervised by your agency and, in certain instances, to relevant materials in the ECIP application. Submission of any or all of the information requested in this form is optional. If the space provided below is insufficient, please attach additional pages as needed.

CONFIDENTIALITY: Information provided herein is subject to Treasury’s disclosure regulations at 31 CFR 1 subpart A and the Freedom of Information Act (FOIA), 5 U.S.C. § 552. Check this box if your agency is providing information for which confidential treatment is requested. Checking the box will result in Treasury contacting your agency if a FOIA request is received for information contained in the form.

3. Assessment of Institution’s Financial Condition

Please provide your agency’s assessment of the current financial condition of the institution and any views regarding the likelihood that the institution will be able to increase its lending in low- and moderate-income communities and/or populations in a safe and sound manner.

[Text]

4. Supervisory Considerations

If applicable, please discuss any material supervisory issues, public enforcement actions, or other relevant issues applicable to the institution, including any publicly documented matters requiring attention. Please note any recent (past 3 years) supervisory history that you feel is relevant to Treasury’s investment.

[Text]

5. Emergency Investment Lending Plan

Please discuss any material concerns you have with the ECIP applicant’s emergency investment lending plan and if you believe the institution has the ability to execute its role under the plan as presented.

[Text]

6. Additional Considerations

Please discuss any additional material concerns not addressed in prior sections. Additionally, please discuss any material concerns with Treasury investing the full amount of capital requested by the ECIP applicant and discuss if you believe a lesser amount would be more appropriate. If the ECIP applicant is a holding company, assume that 100% of the capital investment will be down streamed to the ECIP applicant’s eligible subsidiary bank(s) in proportion to each eligible subsidiary’s assets on the most recent data available on the ECIP applicant’s FR Y-9C.

[Text]

Paperwork Reduction Act Statement:

The information collected will be used for the U.S. Government to evaluate Applicants for investment under the Emergency Capital Investment Program. The estimated burden associated with this collection of information is 8 hours per response. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Office of Privacy, Transparency and Records, Department of Treasury, 1500 Pennsylvania Ave. N.W., Washington, D.C. 20220. DO NOT send the form to this address. 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 control number assigned by OMB.

Treasury is responsible for making the Emergency Capital Investment Program investment decision for this institution. The state regulatory information provided regarding this applicant institution is not a recommendation by its state regulator to Treasury for it to invest in such institution. Treasury understands that this information reflects only the currently available supervisory information and assessment for each institution at the time it is made.

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