Form 6710-07 FDIC Application Pursuant to Section 19 of the FDI Act

OMB Number: 3064-0018
Expiration Date: 10/31/2021

Federal Deposit Insurance Corporation

APPLICATION PURSUANT TO SECTION 19
OF THE FEDERAL DEPOSIT INSURANCE ACT

PRIVACY ACT STATEMENT
The FDIC is authorized to request this information from you by 12 U.S.C § 1829 and Executive Order 9397, as
amended. Your Social Security Number is requested in order to verify the accuracy of the information in this application
and to differentiate you from other individuals with similar or identical names. The FDIC will use this information to
determine your fitness to participate in the conduct of the affairs of the insured institution, and whether your affiliation,
ownership, control or participation in the conduct of its affairs may constitute a threat to the safety and soundness of the
insured institution or the interests of its depositors or threaten to impair public confidence in the insured institution.
Furnishing the requested information is voluntary, but failure to provide the requested information in whole or in part may
delay or prohibit further evaluation of this application. The information you provide is protected by the Privacy Act, 5
USC § 552(a). The information you provide may be provided to appropriate Federal, state, local or foreign law
enforcement authorities; to a court, administrative tribunal, or a party in litigation; and to contractors, agents and other
third parties as authorized by law and in accordance with any of the other routine uses described in the FDIC System of
Records 30-64-0002, Financial Institutions Investigative and Enforcement Records available at http://www.fdic.gov/
about/privacy. If you have questions or concerns about the collection or use of the information, you may contact the
FDIC's Chief Privacy Officer at [email protected].

PAPERWORK REDUCTION ACT NOTICE
The FDIC may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB number. Section 19 of the Federal Deposit Insurance Act (12 U.S.C. § 1829) requires the
FDIC's written consent prior to any participation in the affairs of an insured depository institution by a person who has
been convicted of crimes involving dishonesty, breach of trust, or money laundering. Individuals or insured depository
institutions can seek the FDIC's written consent by filing Section 19 Application Form 6710/07. This form distinguishes
between applications that are sponsored by an insured depository institution and applications that submitted by
individuals requesting a waiver of the institution sponsorship requirement. The estimated burden for this collection of
information is 16 hours per response. Send comments regarding this burden estimate or any other aspect of this
collection, including suggestions for reducing this burden, to the Paperwork Reduction Officer, Legal Division, Federal
Deposit Insurance Corporation, 550 17th Street, N.W., Washington, D.C. 20429

Pursuant to Section 19 of the Federal Deposit Insurance Act, 12 U.S.C. § 1829(a), persons convicted of certain criminal
offenses are prohibited from participating in the affairs of an insured depository institution without the express written
consent of the FDIC. This prohibition applies to any person convicted of a criminal offense involving dishonesty, breach
of trust, or money laundering or who has entered into a pretrial diversion or similar program in connection with a
prosecution for such offense. In the absence of prior FDIC approval, such persons are prohibited from being directly or
indirectly affiliated with an insured depository institution, owning or controlling an insured depository institution, or
otherwise directly or indirectly participating in the conduct of the affairs of an insured depository institution. Insured
depository institutions are also prohibited from permitting such persons from engaging in any of the aforementioned
activities.

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FDIC 6710/07 (8-21)

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OMB Number: 3064-0018
Expiration Date: 10/31/2021

Federal Deposit Insurance Corporation

APPLICATION PURSUANT TO SECTION 19
OF THE FEDERAL DEPOSIT INSURANCE ACT

ATLANTA REGIONAL OFFICE
10 Tenth Street, NW
Suite 800
Atlanta, GA 30309-3849
800-765-3342
States Covered: Alabama, Florida, Georgia, North Carolina,
South Carolina, Virginia, West Virginia

KANSAS CITY REGIONAL OFFICE
1100 Walnut Street
Suite 2100
Kansas City, MO 64106
800-209-7459
States Covered: Iowa, Kansas, Minnesota, Missouri,
Nebraska, North Dakota, South Dakota

BOSTON AREA OFFICE
15 Braintree Hill Office Park
Suite 200
Braintree, MA 02184-8701
866-728-9953
States and Territories Covered: Connecticut, Massachusetts,
Maine, New Hampshire, Rhode Island, Vermont, Puerto Rico,
U.S. Virgin Islands

MEMPHIS AREA OFFICE
6060 Primacy Parkway
Suite 300
Memphis, TN 38119-5770
800-210-6354
States Covered: Arkansas, Louisiana, Mississippi,
Tennessee

CHICAGO REGIONAL OFFICE
300 South Riverside Plaza
Suite 1700
Chicago, IL 60606
800-944-5343
States Covered: Illinois, Indiana, Kentucky, Michigan, Ohio,
Wisconsin

NEW YORK REGIONAL OFFICE
350 Fifth Avenue
Suite 1200
New York, NY 10118
800-334-9593
States Covered: Delaware, District of Columbia,
Maryland, New Jersey, New York, Pennsylvania

DALLAS REGIONAL OFFICE
1601 Bryan Street
Suite 1410
Dallas, TX 75201
800-568-9161
States Covered: Colorado, New Mexico, Oklahoma, Texas

SAN FRANCISCO REGIONAL OFFICE
25 Jessie Street at Ecker Square
Suite 2300
San Francisco, CA 94105-2780
800-756-3558
States and Territories Covered: Alaska, Arizona,
California, Hawaii, Idaho, Montana, Nevada, Oregon,
Utah, Washington, Wyoming, American Samoa, Guam,
Federated States of Micronesia, Northern Mariana
Islands

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Federal Deposit Insurance Corporation

APPLICATION PURSUANT TO SECTION 19
OF THE FEDERAL DEPOSIT INSURANCE ACT
FDIC RULES AND POLICIES WITH RESPECT TO SECTION 19 (12 U.S.C. §1829)

On September 21, 2020, the FDIC entered into its Rules of Practice and Procedure Part 303, Subpart L: Section 19 of
the FDI Act (Consent to Service of Persons Convicted of, or Who Have Program Entries for, Certain Criminal Offenses)
(12 C.F.R. part 303, subpt. L) (Subpart L). Subpart L replaces the FDIC's former Statement of Policy on Section 19 and
establishes the FDIC's standards for implementing Section 19 of the Federal Deposit Insurance Act (12 U.S.C. § 1829)
(Section 19) and for accepting and processing applications filed under Section 19. Applicants should review Subpart L,
these application instructions, the FDIC's informational brochure Your Guide to Section 19, and contact the applicable
FDIC Regional or Area Office prior to filing an application. These resources can be found at https://www.fdic.gov/
regulations/applications/resources/section19.html.
As amended by the Financial Institutions Reform, Recovery and Enforcement Act of 1989, the Comprehensive Thrift and
Bank Fraud Prosecution and Taxpayer Recovery Act of 1990, and the Financial Services Relief Act of 2006, Section 19
prohibits, without the prior written consent of the FDIC, a person convicted of any criminal offense involving dishonesty
or breach of trust or money laundering (covered offenses), or who has entered into a pretrial diversion or similar program
(Program Entry) in connection with a prosecution for such covered offense, from becoming or continuing as an
institution-affiliated party, owning or controlling, directly or indirectly, an insured depository institution, or otherwise
participating, directly or indirectly, in the conduct of the affairs of an insured depository institution (covered individual). In
addition, Section 19 forbids an insured depository institution from permitting such a person to engage in any conduct or
to continue any relationship prohibited by Section 19.
The FDIC is precluded from granting consent for ten years, beginning on the date the conviction or agreement of the
person becomes final, to a person convicted of certain crimes enumerated in Title 18 of the United States Code, absent
a motion by the FDIC and approval by the sentencing court. Convictions or Program Entries for a violation of the Title 18
sections specified in Section 19 cannot qualify for the de minimis exceptions described below.
Whoever knowingly violates the prohibitions of Section 19 shall be fined not more than $1,000,000 for each day such
prohibition is violated or imprisoned for not more than five years, or both.
De Minimis Rule: Automatic Consent
Subpart L provides that consent is automatically granted and an application will not be required where the covered
offense is considered de minimis. Subpart L establishes general de minimis criteria where any conviction or Program
Entry for a covered offense may qualify, and further states that the de minimis exception will apply to specified
circumstances and offenses. The general de minimis rule and the additional categories of de minimis rules are
described below.
(a) De Minimis Offenses - In General
Approval is automatically granted and an application will not be required where the covered offense is
considered de minimis because it meets all of the following criteria:
•

There are no more than two convictions or Program Entries of record for a covered offense; and

•

Each offense was punishable by imprisonment for a term of one year or less and a fine of $2,500 or less, and
the individual served 3 days or less of jail time; and

•

All of the sentencing requirements associated with the conviction, or conditions imposed by the Program
Entry, have been completed; and

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•

The offense was not committed against an insured depository institution or insured credit union; and

•

If there are two de minimis covered offenses, each conviction or Program Entry was entered at least 3 years
before an application would otherwise be required (i.e., prior to the date that the most recent conviction or
Program Entry began).
The FDIC considers jail time to include any significant restraint on an individual's freedom of movement which
includes, as part of the restriction, confinement to a specific facility or building on a continuous basis where
the person may leave temporarily only to perform specific functions or during specified times periods or both.
Jail time includes confinement to a psychiatric treatment center in lieu of a jail, prison, or house of correction
on mental-competency grounds. The definition is not intended to include any of the following: (i) persons on
probation or parole who may be restricted to a particular jurisdiction, or who must report occasionally to an
individual or to a specified location; (ii) persons who are restricted to a substance-abuse treatment program
facility for part or all of the day; and (iii) persons who are ordered to attend outpatient psychiatric treatment.

(b) De Minimis Offenses - Additional Categories
Age at Time of Covered Offense
•

If there are two convictions or Program Entries for a covered offense, and the actions that resulted in the
convictions or Program Entries all occurred when the individual was 21 years of age or younger, then the
general de minimis criteria in (a), above, shall apply, except that the waiting period is reduced to 18 months
(not 3 years).
NOTE: All of the sentencing requirements associated with the conviction, or conditions imposed by the
Program Entry, must be completed.

Convictions or Program Entries for Small-Dollar, Simple Theft
•

Convictions or Program Entries based on a simple theft of goods, services and/or currency (or other
monetary instrument) shall be considered de minimis offenses if the following conditions apply:
o

The value of the currency, goods, or services taken is $1,000 or less; and

o

The theft was not committed against an insured depository institution or insured credit union; and

o

The convictions or Program Entries did not include burglary, forgery, robbery, identity theft, or fraud; and

o

The individual has no more than one other de minimis offense subject to Section 19; and

o

If there are two de minimis covered offenses under any category, each conviction or Program Entry was
entered at least 3 years before an application would otherwise be required (i.e., such time must pass
since the date that the most recent conviction or Program Entry began) or at least 18 months prior to the
date an application would otherwise be required if the actions that resulted in the conviction or Program
Entry all occurred when the individual was 21 years of age or younger.

NOTE: All of the sentencing requirements associated with the conviction, or conditions imposed by the
Program Entry, must be completed.
Convictions or Program Entries for Insufficient Funds Checks
•

Convictions or Program Entries based on the writing of "bad" or insufficient funds check(s) shall be
considered a de minimis offense if the following conditions apply:
o

FDIC 6710/07 (8-21)

The aggregate total face value of all “bad” or insufficient funds check(s) cited across all the conviction(s)
or Program Entry(ies) for bad or insufficient funds checks is $1,000 or less; and

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o

No insured depository institution or insured credit union was a payee on any of the “bad” or insufficient
funds checks that were the basis of the conviction(s) or Program Entry(ies); and

o

Other than for bad checks, the individual has no more than one other de minimis offense subject to
Section 19.

NOTE: For “bad” checks offenses, the individual need not have completed all of the sentencing requirements
associated with the conviction, or conditions imposed by the Program Entry, before the covered offense may
qualify as de minimis.
Convictions or Program Entries for the Use of a Fake, False, or Altered Identification Card
• Convictions or Program Entries for the creation or possession of a fake, false, or altered form of identification
by a person under the age of 21 or for the use of such identification by a person under the age of 21 to
circumvent age-based restrictions on purchases, activities, or premises entry, shall be considered de minimis
if the following conditions apply:
o

The individual has no more than one other de minimis offense subject to Section 19, and

o

If there are two de minimis covered offenses under any category, each conviction or Program Entry was
entered at least 3 years before an application would otherwise be required (i.e., such time must pass
since the date that the most recent conviction or Program Entry began) or at least 18 months prior to the
date an application would otherwise be required if the actions that resulted in the conviction or Program
Entry all occurred when the individual was 21 years of age or younger.

NOTE: For fake identification offenses, the individual need not have completed all of the sentencing
requirements associated with the conviction, or conditions imposed by the Program Entry, before the covered
offense may qualify as de minimis.
In addition, Subpart L requires that any person who meets these criteria must be covered by a fidelity bond to the same
extent as others in similar positions. A person availing themselves of the automatic consent under this provision is
required to disclose the presence of the conviction or Program Entry to which they have claimed such consent pursuant
to the de minimis criteria to all insured depository institutions in which affairs such person will participate. If an insured
depository institution or person avails themselves of the criteria, the institution should maintain documentation to support
the de minimis nature of the covered crime(s).
Written Application for FDIC Consent
There are two methods by which a covered individual can apply to the FDIC for written permission to become an
institution-affiliated party or participate in the affairs of an insured depository institution. The first method involves an
insured depository institution filing a Section 19 application on behalf of a prospective director, officer, or employee
(Sponsorship). When an insured depository institution will not file a Section 19 application on behalf of a covered
individual, a second method allows that individual to seek a waiver of the requirement that an insured depository
institution file a Section 19 application on their behalf (Individual Waiver).
Sponsorship
When an application is required, forms and instructions should be obtained from, and the application filed with, the
appropriate FDIC Regional or Area Office where the sponsoring institution is headquartered (a list of FDIC Offices is
included in this application). Only an insured depository institution may file an application on behalf of a covered
individual, under Section 19, unless the FDIC first grants a waiver for an individual to file a Section 19 application on his
or her behalf. Sponsorship applications are generally intended to allow the covered individual to work in a specific job at
a specific institution and may also be subject to the condition that the prior consent of the FDIC will be required for any
proposed significant changes in the person's duties or responsibilities. Upon FDIC review, such proposed changes may
require a new application. Sponsorship approvals are not transferable to another insured institution. If the FDIC has
granted approval for a person to participate in the affairs of a particular insured institution, and that person subsequently
seeks to participate at another insured depository institution, another application must be submitted.

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Individual Waivers
Individual Waivers per Section 19 will be considered on a case-by-case basis where substantial good cause exists for
granting the waiver. An application for an Individual Waiver and for consent to participate in the affairs of an insured
depository institution are both contained within this form and must be submitted to the appropriate FDIC Regional or
Area Office where the applicant currently resides. Since de minimis offenses may qualify for automatic approval (see de
minimis discussion above), the expectation is that Individual Waivers will be granted only in truly meritorious cases and
upon good cause shown. For Individual Waivers, the FDIC's approval results in the issuance of a published order and
allows the covered individual to participate in the affairs of any insured depository institution in any capacity, subject to
the FDIC's conditions of approval. The approval is limited to the convictions or Program Entries covered by the order. If
such covered individual is convicted or enters into a pretrial diversion or similar program for a subsequent offense
covered by Section 19, he or she is prohibited from participating in the affairs of any insured depository institution and
must reapply to the FDIC via the Sponsorship or Individual Waiver process, unless the offense is considered de minimis.
If an individual is seeking a waiver, do not complete Sections I & II of the application. An individual should complete
Sections IV, V, and VI, and in particular the INDIVIDUAL WAIVER STATEMENT, as well as the INDIVIDUAL WAIVER
CERTIFICATION.
Application Considerations
I.

STANDARDS TO BE APPLIED IN DETERMINING WHETHER AN APPLICATION FOR CONSENT IS REQUIRED
UNDER SECTION 19
Section 19 applies to employees of an insured depository institution as well as to any other person who is in a
position to influence control over the management or participate in the affairs of an insured depository institution.
Please note that in addition to the requirement to file an application with the FDIC, some individuals may also need to
comply with any filing requirements established by the Board of Governors of the Federal Reserve System, in the
case of a bank holding company or savings and loan holding company. Absent the FDIC's written approval, persons
covered by Section 19 are precluded from owning or controlling an insured depository institution. A person will be
deemed to exercise "control" if that person has the power to vote 25 percent or more of the voting shares of an
insured depository institution (or 10 percent of the voting shares if no other person has more shares) or the ability to
direct the management or policies of the institution. Under the same standards, a person will be deemed to "own" an
insured depository institution if that person owns 25 percent or more of the institution's voting stock, or 10 percent of
the voting shares if no other person owns more. These standards would also apply to an individual acting in concert
with others so as to have such ownership or control. Absent the FDIC's consent, persons subject to the prohibitions
of Section 19 will be required to divest their control or ownership of shares above the foregoing limits. The following
standards are used in the determination as to whether Section 19 is applicable.
A. There must be a conviction of record. Section 19 does not cover arrests, pending cases not brought to trial,
acquittals, or any conviction that has been reversed on appeal, unless the reversal was for the purpose of resentencing. A conviction that is being appealed will require a Section 19 application until or unless otherwise
reversed. If an order of expungement or an order to seal has been issued in regard to a conviction, or if a record
has been otherwise expunged by operation of law, then the conviction shall not be considered a conviction of
record and shall not require an application. A conviction for which a pardon has been granted will require an
application.
Entrance into pretrial diversion or similar program. A Program Entry, whether formal or informal, is characterized
by a suspension or eventual dismissal of charges or criminal prosecution often upon agreement by the accused
to treatment, rehabilitation, restitution, or other noncriminal or non-punitive alternatives. Whether a program
constitutes a pretrial diversion or similar program is determined by relevant federal, state, or local law, and if not
so designated under applicable law, then the determination of whether it is a pretrial diversion or similar program
will be made by the FDIC on a case-by-case basis. Participation in a Program Entry in connection with a
prosecution for a covered offense is included within the provisions of Section 19, and an application is required.
If, after successful completion of a Program Entry, the initial charge for a covered offense is reduced to a charge
for an offense that is not a covered offense, or is dismissed, the offense will require an application unless the
initially charged offense is de minimis. Program Entries that are expunged or sealed will be treated the same as
expunged or sealed convictions and shall not require an application. Program Entries prior to November 29,
1990, are not covered by Section 19.

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Before an application is considered by the FDIC, all of the sentencing requirements associated with a conviction
or conditions imposed by the Program Entry, including but not limited to, imprisonment, fines, condition of
rehabilitation, and probation requirements, must be completed, and the case must be considered final by the
procedures of the applicable jurisdiction.
B. The conviction or Program Entry must be for a criminal offense involving dishonesty, breach of trust, or money
laundering. Misdemeanors as well as felonies are included. “Dishonesty” means directly or indirectly to cheat or
defraud, to cheat or defraud for monetary gain or its equivalent, or wrongfully to take property belonging to
another in violation of any criminal statute. Dishonesty includes acts involving lack of integrity; lack of probity; or
a disposition to distort, cheat, or act deceitfully or fraudulently, and may include crimes that federal, state, or local
laws define as dishonest. “Breach of trust” means a wrongful act, use, misappropriation, or omission with respect
to any property or fund that has been committed to a person in a fiduciary or official capacity, or the misuse of
one's official or fiduciary position to engage in a wrongful act, use, misappropriation, or omission. Whether a
crime involves dishonesty or breach of trust will be determined from the statutory elements of the crime itself.
The FDIC Board has determined that Section 19 applies to certain drug-related crimes. All convictions or
Program Entries for offenses concerning the illegal manufacture, sale, distribution of, or trafficking in controlled
substances shall require an application, unless they fall within the provisions for de minimis offenses. Convictions
or Program Entries for criminal offenses involving the simple possession of a controlled substance are not
covered under Section 19.
C. Youthful Offenders
Adjudication by a court against a person as a “youthful offender” under any youth offender law or adjudication as
a “juvenile delinquent” by a family court or any other court having jurisdiction over minors as defined by state law
will not require an application under Section 19. Such adjudications are not considered convictions for criminal
offenses.
D. Adults and All Minors Convicted of Crimes
The conviction of any adult or minor by a court of competent jurisdiction for any criminal offense involving
dishonesty, breach of trust, or money laundering as defined in paragraph B and not excluded under the
automatic consent provision of the de minimis criteria will require an application to, and consent by, the FDIC
prior to an insured depository institution's employment of such person, or such person owning or controlling,
directly or indirectly, the insured depository institution, or otherwise participating in the affairs of an insured
depository institution.
II.

EVALUATION OF APPLICATIONS MADE UNDER SECTION 19
A. The essential criteria in assessing an application is whether the person has demonstrated his or her fitness to
participate in the conduct of the affairs of an insured depository institution, and whether the affiliation, ownership,
control, or participation by the person in the conduct of the affairs of the insured depository institution may
constitute a threat to the safety and soundness of the insured depository institution or the interests of its
depositors or threaten to impair public confidence in the insured depository institution. In determining the degree
of risk, the FDIC will consider certain factors for both Sponsorship applications and Individual Waiver
applications. These factors are:
• The conviction or Program Entry and the specific nature and circumstances of the covered offense;
• Evidence of rehabilitation, including the person's age at the time of conviction or Program Entry, the amount
of time that has elapsed since the conviction or Program Entry, and the person's employment history and
full legal history;
• The position to be held or the level of participation by the person at an insured institution;
• The amount of influence the person will be able to exercise over the operation, management, or affairs of
an insured depository institution;

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• The ability of management of the insured institution to supervise and control the person's activities;
• The level of ownership or control the person will have at the insured institution;
• The applicability of the insured depository institution's fidelity bond coverage to the person;
• The opinion or position of the primary federal or state regulator; and
• Any additional factors in the specific case that appear relevant.
B. These are the important considerations in determining the risk to insured depository institutions. However,
Sponsorship applications differ from Individual Waiver applications in several aspects. In a Sponsorship
application, an insured depository institution seeks the FDIC's consent for the covered individual to participate
only in a specific role at the sponsoring institution. The sponsoring depository institution is aware of the covered
individual's conviction and rehabilitation history and is willing to sponsor that individual. The depository institution,
in applying on behalf of a covered individual, has agreed to supervise the covered individual for a specific duty or
job range and must ensure the person is covered by the institution's fidelity bond to the same extent as others in
similar positions. Furthermore, the degree of scrutiny accorded a Sponsorship application will be directly
proportional to the individual's proposed position.
C. When evaluating Individual Waiver applications, the FDIC must consider that, upon issuance of an order granting
a waiver and approval, generally, the covered individual will not be barred by Section 19 from holding any
position or participating to any extent in the ownership, affairs, or influence over management of any insured
depository institution. In addition, the FDIC is unable to assess the degree of supervision and controls that may
prospectively exist over the covered individual's activities at any insured depository institution. Accordingly, such
consent is granted only in meritorious cases where the applicant has demonstrated substantial good cause and a
record of rehabilitation sufficient to mitigate the seriousness of the offense. The record of rehabilitation must be
detailed, commensurate with the seriousness of the offense, and demonstrate that the individual is fit to
participate in the conduct of the affairs of an insured financial institution. Item number 22 in Section V of this
application form provides examples of documentation that may be submitted as evidence of rehabilitation.
Approved Individual Waiver orders are generally subject to conditions. The conditions typically require the
covered individual to provide a copy of the FDIC's order to all insured institutions in the affairs of which he or she
intends to participate and that the covered individual be covered by fidelity insurance to the same extent as those
who hold similar positions. Other conditions may be imposed as deemed appropriate.

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Federal Deposit Insurance Corporation

APPLICATION PURSUANT TO SECTION 19
OF THE FEDERAL DEPOSIT INSURANCE ACT
INSTRUCTIONS: Insured Depository Institutions must complete SECTIONS I, II, IV, V, VI, VII, and IX. Individual
applicants must complete SECTIONS IV, V, VI, VIII, and X. Both Insured Depository Institutions and Individual
applicants must review SECTION III. If the application involves more than one covered offense, additional copies of
SECTION V or additional pages labeled as “SECTION V” must be submitted for each covered offense.
Type of Applicant:

Insured Depository Institution

Individual

SECTION I - INSURED DEPOSITORY INSTITUTION INFORMATION
1. Name of Insured Depository Institution

2. Date of Application

3. Address (Street, City, County, State, and ZIP Code)
SECTION II - POSITION TO BE OCCUPIED BY THE COVERED INDIVIDUAL IF THEY ARE A PROSPECTIVE
DIRECTOR, OFFICER, OR EMPLOYEE
4. Title of Position(s) or Prospective Position(s)

5. Describe the duties and responsibilities of the prospective director, officer, or employee. Include extent of supervision
exercised, or potentially exercised, over others and/or by others.

SECTION III - NOTIFICATION OF FIDELITY INSURER
The insured depository institution's fidelity insurer is to be notified of all pertinent information regarding the
conviction of the prospective employee. Assurances from the fidelity insurer must be obtained, in writing,
stating that the prospective director (if applicable), officer, or employee will be covered by the insured
depository institution's fidelity bond. This application and the information requested herein may be submitted prior to
notification of the bonding company. However, the FDIC's consent will be subject to a condition that written assurance
of fidelity coverage to the same extent as others in similar positions be obtained by the insured depository institution.
PROCEED TO SECTION D
SECTION IV - BIOGRAPHICAL INFORMATION OF THE COVERED INDIVIDUAL*
* In addition to a completed Form 6710/07, additional documentation and instructions for the completion of the
fingerprinting process will be provided by the applicant's respective FDIC Regional or Area Office contact. Further,
other items may be requested and will be identified in the application or sought on a case-by-case basis.
6. Name

7. Date of Application

8. Address (Street, City, County, State, and ZIP Code)
9. Telephone
FDIC 6710/07 (8-21)

10. Date of Birth

11. Place of Birth

12. Social Security Number
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13. Name of Most Recent Employer
14. Address of Most Recent Employer (Street, City, State, and ZIP Code)

15. Indicate the total number of voting shares of the Insured Depository Institution (Proposed Employer) stock directly or
indirectly owned or otherwise controlled by the covered individual. (Answer "non" if appropriate.)

SECTION V - INFORMATION RELATIVE TO CONVITION(S) OR PERTRIAL DIVERSION OR SIMILAR PROGRAM(S)
NOTE: If the Applicant is subject to more than one covered offense, attach additional pages labeled as “SECTION V,”
and provide all the information relative to the conviction(s) or pretrial diversion or similar program(s).
16. Title and Citation of Crime

17. Date of Conviction or Date of Pretrial Diversion or Similar Program Entry..................................
18. Name of Court
19. Address of Court (Street, City, State, ZIP Code)
20. Disposition

NOTE: This application covers only those convictions or entry into pretrial diversion or similar programs listed in this
Section. If additional convictions or completion of pretrial diversion or similar programs for crimes involving dishonesty or
breach of trust or money laundering are discovered subsequent to approval of this request, the applicant will be
prohibited by Section 19 from participating in the affairs of an insured depository institution. A subsequent application
pursuant to Section 19 will be required.
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21. Briefly describe the nature of the offense and the circumstances surrounding it. Include age of the individual at the
time of the actions that resulted in the conviction or Program Entry, date of the offense, and any mitigating circumstances
(parole, suspension of sentence, pardon, etc.)

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OMB Number: 3064-0018
Expiration Date: 10/31/2021

22. Briefly describe the extent of rehabilitation of the covered individual and attach supporting documents, if any (e.g., a
resume, school transcripts). Evidence of an individual's rehabilitation may include:
• Subsequent convictions or lack thereof;
• Employment history after conviction or completion of pretrial diversion or similar programs, highlighting any
demonstrated fiduciary responsibility;
• Letters of reference from current or former employers, influential members of the community, or probation or
parole officers;
• Subsequent educational achievements, if any. Documentation must be provided to support any educational
achievement;
• If currently going to school, letter of references from a professor, dean, or other school official; or
• Community service or volunteer work.
NOTE: Please provide contact information for individuals who may be contacted to verify evidence of rehabilitation for
each item you wish to have considered as evidence of your rehabilitation. References have greater weight
when the party providing the reference is aware of the individual's prior history.

FDIC 6710/07 (8-21)

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OMB Number: 3064-0018
Expiration Date: 10/31/2021

23. Attach copies of the Indictment, Information, or Complaint and Final Decree of Judgment, or documentation to
support the completion of a Pretrial Diversion or Similar Program, if available. (Normally these can be obtained from the
clerk of the court or prosecutor's office. If not provided, explain reasons for unavailability.)
Attach File(s)

24. List any other pertinent facts relative to the crime that are not disclosed in the Indictment, Information, or Complaint
and Final Decree of Judgment.

SECTION VI - ACKNOWLEDGEMENT OF COVERED INDIVIDUAL
I understand that the FDIC may conduct extensive checks into my background, experience, and related matters in
conjunction with my application. I consent to and authorize collection agencies, credit bureaus, law enforcement
agencies, consumer reporting agencies, and other sources of information to provide information about me including, but
not limited to, financial, credit, tax, immigration, and criminal investigative information to the FDIC for the purpose of
making a determination as to my experience, competence, integrity, character, financial ability, and willingness to direct,
lead or participate in a bank's affairs in a safe, sound, and legal manner. I do hereby certify that the Biographical
Information (Section IV) and Information Relative to Conviction(s) or Pretrial Diversion or Similar Program (Section V)
are true and correct to the best of my knowledge and belief.
25. Name of Covered Individual
FDIC 6710/07 (8-21)

26. Signature

27. Date
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OMB Number: 3064-0018
Expiration Date: 10/31/2021

NOTE: The information requested in Sections IV and V above, including the Social Security Number of the covered
individual is solicited pursuant to Section 19 of the Federal Deposit Insurance Act (12 U.S.C. § 1829). This information is
necessary to assist the FDIC in assessing the merits of the application. Some of the information, including the Social
Security Number, may be provided to any appropriate federal or state insured depository institution regulatory agency
and law enforcement or other governmental agencies for identity verification purposes. Should the information indicate a
violation of law, the application may be referred to any agency responsible for investigating or prosecuting such a
violation. In addition, in the event of litigation, the application may be presented to the appropriate court as evidence and
to counsel in the course of discovery. While submission of the information is voluntary, an omission or inaccuracy may
result in a delay in processing the application, a return of the application as incomplete, or a denial of the application.
Falsification of any of the information may serve as a basis for denial of the application or the removal of the director,
officer, or employee if employed by the insured depository institution as well as grounds for criminal charges.

INSURED DEPOSITORY INSTITUTIONS SHOULD PROCEED TO SECTION VII

INDIVIDUAL APPLICANTS SHOULD PROCEED TO SECTION VIII
SECTION VII - ADDITIONAL INFORMATION IN SUPPORT OF THIS REQUEST
28. Insured depository institutions may list any other appropriate information. (Enter “NONE” if desired.)

INSURED DEPOSITORY INSTITUION SHOULD PROCEED TO THE CERTIFICATION FOR APPLICATION
SECTION VIII - INDIVIDUAL WAIVER STATEMENT
29. If an individual is seeking a waiver of the requirement that an insured depository institution file a Section 19
application on his/her behalf, provide a summary statement in the space below describing why the FDIC should grant the
waiver of the institution filing requirement in their case. (Use additional sheets if needed)

INDIVIDUAL APPLICANTS SHOULD PROCEED TO THE INDIVIDUAL CERTIFICATION FOR WAIVER AND
APPLICATION
SECTION IX - INSURED DEPOSITORY INSTITUTION CERTIFICATION FOR APPLICATION
I do hereby certify that the Board of Directors adopted a resolution, which delegated the undersigned the authority to
make applications pursuant to Section 19 of the Federal Deposit Insurance Act or has adopted a resolution authorizing
this application pursuant to Section 19 of the Federal Deposit Insurance Act.
30. Name of Insured Depository Institution Official
32. Signature
FDIC 6710/07 (8-21)

31. Title of Insured Depository Institution Official
33. Date
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OMB Number: 3064-0018
Expiration Date: 10/31/2021

SECTION X - INDIVIDUAL CERTIFICATION FOR WAIVER AND APPLICATION
To be signed by the individual seeking a waiver of the requirement that an insured depository institution file a Section 19
application on his/her behalf.
I certify that, to the best of my knowledge and belief, all of the information on and attached to this waiver application is
true, correct, and complete and provided in good faith. I understand that falsification of any of the information may serve
as a basis for my removal as an employee of an insured depository institution and as grounds for criminal charges. I
understand that any information I give may be investigated. I further understand that any decision made regarding my
individual waiver and application will be a public document, and will be posted on the FDIC's website.
34. Individual Seeking Waiver

35. Signature

36. Date

This is an official document of the Federal Deposit Insurance Corporation. Providing false information may be grounds for
prosecution under the provisions of Title 18, Section 1001 or 1007 of the United States Code and may be punishable by fine
or imprisonment.

FDIC 6710/07 (8-21)

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