Agency Office Additional Services Application

Office of the Comptroller of the Currency

OMB no. 1557-0014

Expiration date: See www.occ.gov

Agency Office Additional Services Application

General Information and Instructions

Preparation and Use

This application is used to effect a transaction under 12 CFR 5.31(k)(2) for a federal savings association (bank) to conduct additional services in a new or existing agency office.

All questions must be answered with complete and accurate information that is subject to verification. If the answer is “none,” “not applicable,” or “unknown,” so state. Answers of “unknown” should be explained.

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

This application form collects information that the OCC will need to evaluate an Additional Services application. The applicant may contact the OCC directly for specific instructions.

Notice of Publication

Generally, public notice under 12 CFR 5.8 does not apply to an Additional Services request application, unless the OCC determines that the application presents a significant or novel policy, supervisory, or legal issue where a public notice is considered necessary. A public notice also may be required where an additional services application is accompanied by a second application that requires a publication notice under 12 CFR 5.8. In this instance, a public notice describing the entire transaction may be necessary to ensure the public has a full understanding of the entire transaction.

If a notice is required, the applicant must publish notice of the proposed additional services at the agency office in a newspaper of general circulation in the community or communities in which the applicant proposes to engage in business. The OCC will provide specific requirements for the notice of publication.

Submission

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

Confidentiality

Any applicant desiring confidential treatment of specific portions of the application must submit a request in writing with the application. The request must discuss the justification for the requested treatment. The applicant’s reasons for requesting confidentiality should specifically demonstrate the harm (for example, loss of competitive position, invasion of privacy) that would result from public release of information (5 USC 552 or relevant state law). Information for which confidential treatment is requested should be (1) specifically identified in the public portion of the application (by reference to the confidential section); (2) separately bound; and (3) labeled “Confidential.” The applicant should follow the same procedure when requesting confidential treatment for the subsequent filing of supplemental information to the application. Contact the OCC for any further questions regarding requests for confidential treatment.

Agency Office Additional Services Application

Applicant

________________________________________________________________________

Name Charter no.

________________________________________________________________________

Current street address

________________________________________________________________________

City County State Zip code

Parent Company Identifying Information (if applicable)

________________________________________________________________________

Name

________________________________________________________________________

Street

________________________________________________________________________

City State Zip code

Contact Person

________________________________________________________________________

Name Title

________________________________________________________________________

Employer

________________________________________________________________________

Street

________________________________________________________________________

City State Zip code

________________________________________________________________________

Telephone no. Fax no. E-mail address

Agency Office Additional Services Application

Overview

1. Please describe in detail the type of additional services the bank will be performing at the agency office(s).

2. Please provide a business plan describing the bank’s organizational structure including its agency office(s), management of the additional services, and financial projections for the new services. Provide pro forma financial statements for the bank, reflecting the additional services over the next three fiscal years. Discuss the bank’s ability to support the new services, including potential operating losses, and their impact on the bank’s overall financial condition.

3. Discuss in detail the intended use of affiliates or other related entities to support the proposed additional services.

4. Provide résumés and discuss specific qualifications of anticipated senior management, e.g., senior vice president, executive vice president, to support the proposed additional services.

OCC CERTIFICATION

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

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

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

_______________________________________

President or other authorized officer

_______________________________________

Typed name

_______________________________________

Title

_______________________________________

Employer

1