Compare version of Form 6710-07 Showing NS Revisions

OMB No.: 3064-0018

Expiration Date: 10/31/2021

FEDERAL DEPOSIT INSURANCE CORPORATION

APPLICATION PURSUANT TO SECTION 19

OF THE FEDERAL DEPOSIT INSURANCE ACT

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.

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

South Carolina, Virginia, West Virginia

DALLAS REGIONAL OFFICE

KANSAS CITY REGIONAL OFFICE

Nebraska, North Dakota, South Dakota

Page

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.

Page down to access form 6710/07

ATLANTA REGIONAL OFFICE

10 Tenth Street, NW

Suite 800

Atlanta, GA 30309-3849

800-765-3342

States Covered:Alabama, Florida, Georgia, North Carolina,

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

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

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

FDIC RULES AND POLICIES WITH RESPECT TO SECTION 19 (12 U.S.C. §1829)

(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 processingSection 19 of the FDI Act (Consent to Service of Persons Convicted of, or Who Have Program Entries for, Certain Criminal Offenses) On September 21, 2020, the FDIC entered into its Rules of Practice and Procedure Part 303, Subpart L: 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 regulations/applications/resources/section19.html HYPERLINK "https://www.fdic.gov/regulations/applications/resources/section19.html" \h https://www.fdic.gov/ HYPERLINK "https://www.fdic.gov/regulations/applications/resources/section19.html" \h

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

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

• If there are two 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). de minimis

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:

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

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

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

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

• If there are two covered offenses under any category, each de minimisconviction 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 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:

  • 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

  • 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

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

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 Small-Dollar, Simple Theft

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:

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

  • If there are two 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. 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)de minimis

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.

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.

1. 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 require an application. notA conviction for which a pardon has been granted will require

1. 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 . Program Entries that are expunged or sealedde minimis 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.

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.

2. 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.

3. 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.

4. 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

1. 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;

   • 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.

2. 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.

3. 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.

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.

Individual Insured Depository InstitutionType of Applicant:

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)

4. 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	10. Date of Birth	11. Place of Birth	12. Social Security Number

13. Name of Most Recent Employer

13. Address of Most Recent Employer (Street, City, State, and ZIP Code)

13. 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

16. Date of Conviction or Date of Pretrial Diversion or Similar Program Entry..................................

16. 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.

20. 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.)

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.

22. 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.)

22. 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 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	31. Title of Insured Depository Institution Official
32. Signature		33. Date

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

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 (8-18)