Disclosure

DRAFT
FR LL 10(e)
OMB Number XXX
Approval expires XXX XX, 20XX
Page 1 of 2

Board of Governors of the Federal Reserve System

Application to Become a Savings and Loan
Holding Company or to acquire a Savings
Association or Savings and Loan Holding
Company (LL-10(e))

Corporate Title of Applicant
Street Address
City

State

Zip Code

(Type of organization, such as corporation, partnership, business trust, association, or trust)

Hereby applies to the Board pursuant to section l0(e) of Home Owners’ Loan Act (“HOLA”), 12 U.S.C. 1461 et. seq.; and 12 CFR
238.11(a) through (f),
for prior approval of the acquisition of direct or indirect ownership, control, or power to vote at least
a class of voting shares or otherwise to control:
Number

(

%) of
Percent

Hereby is forming a new holding company as part of a reorganization pursuant to section 10(e)(1)(B) of HOLA; and 12
CFR 238.12(a)(2):
Corporate Title of Savings Association or Savings and Loan Holding Company
Street Address
City

State

Zip Code

Does applicant request confidential treatment for any portion of
this submission?

Yes
As required by the General Instructions, a letter justifying
the request for confidential treatment is included.
The information for which confidential treatment is being
sought is separately bound and labeled "Confidential.”

No

0X/20X
X

FR LL 10(e)
Page 2 of 2

Name, title, address, telephone number, and facsimile number of person(s) to whom inquiries concerning this application may be directed:
Name

Name

Title

Title

Street Address

Street Address

City

State

Zip Code

City

Area Code / Phone Number

Area Code / Phone Number

Area Code / FAX Number

Area Code / FAX Number

State

Zip Code

Certification
I certify that the information contained in this application has been
examined carefully by me and is true, correct, and complete, and
is current as of the date of this submission to the best of my
knowledge and belief. I acknowledge that any misrepresentation
or omission of a material fact constitutes fraud in the inducement
and may subject me to legal sanctions provided by 18 U.S.C.
§1001 and §1007.
I also certify, with respect to any information pertaining to an individual and submitted to the Board in (or in connection with) this
application, that the applicant has the authority, on behalf of the
individual, to provide such information to the Board and to consent
or to object to public release of such information. I certify that the
applicant and the involved individual consent to public release of
any such information, except to the extent set forth in a written
request by the applicant or the individual, submitted in accordance
with the Instructions to this form and the Board’s Rules Regarding

Signed this

day of
Day

,
Month

Availability of Information (12 C.F.R. Part 261), requesting confidential treatment for the information.
I acknowledge that approval of this application is in the discretion
of the Board of Governors of the Federal Reserve System (the
“Federal Reserve”). Actions or communications, whether oral,
written, or electronic, by the Federal Reserve or its employees in
connection with this filing, including approval if granted, do not
constitute a contract, either express or implied, or any other
obligation binding upon the agency, the United States or any other
entity of the United States, or any officer or employee of the United
States. Such actions or communications will not affect the ability of
the Federal Reserve to exercise its supervisory, regulatory, or
examination powers under applicable laws and regulations. I
further acknowledge that the foregoing may not be waived or
modified by any employee or agency of the Federal Reserve or of
the United States.

.
Year

Signature of Chief Executive Officer or Designee

Print or Type Name

Title

0X/20X
X