FR 2086a

DRAFT

FR 2086a
OMB Number 7100-0042
Approval expires February 28, 2025
Page 1 of 1

FOR USE BY MEMBER BANKS CONVERTING INTO OR MERGING
INTO MEMBER OR NONMEMBER BANKS OR COVERED
SAVINGS ASSOCIATIONS (CSAs) TERMINATING AN ELECTION
TO OPERATE AS A CSA.

Board of Governors of the Federal Reserve System

Application for Cancellation of
Federal Reserve Bank Stock—FR 2086a

Date of Application

At a meeting of the

of

Stockholders or Board of Directors

City or Town

State

Legal Name of Bank

, (Charter Number

requirements of the charter, articles of incorporation or bylaws of said bank and held on the
the following resolution was duly adopted:

) called pursuant to the

Day

day of

Month

,

Year

,

“WHEREAS, after due and legal notice, the stockholders of this bank have voted to (merge/consolidate the bank into a member or nonmember state bank) (convert the bank into a nonmember bank) in accordance with law, and
“WHEREAS, under the provisions of section 9 of the act approved December 23, 1913, as amended, and known as the Federal
Reserve Act, this bank is required to surrender for cancellation all of its holdings of the capital stock of the Federal Reserve Bank of
and to terminate its membership in the Federal Reserve System.
“NOW, THEREFORE, BE IT RESOLVED, that the President, Chief Financial Officer or Vice President and the Cashier or Secretary
be, and they are hereby, authorized, empowered, and directed to make application for the cancellation of
shares of stock allocated to and held by this bank and to receive any balance due this bank by said Federal Reserve Bank on account
of cash paid subscriptions, or otherwise, and any securities or other valuables belonging to this bank and to do such acts as may be
necessary to adjust and settle the accounts between this bank and the said Federal Reserve Bank.”
I hereby certify that the foregoing is a true and correct copy of a resolution adopted and recorded in the minutes of the meeting of the
of this bank held on the date specified.
Stockholders or Board of Directors

Cashier, Secretary, or Treasurer

In pursuance of the foregoing resolution, I hereby make application on behalf of

Legal Name of Bank

City or Town

State

ABA Number

for the cancellation of
shares of stock heretofore allotted to it and for the refund of all moneys, securities, or
other valuables due to it by the Federal Reserve Bank of
on account of cash
paid subscriptions, or otherwise.

Name of President, Chief Financial Officer or Vice
President Name of Cashier, Treasurer, or Secretary

By:
Attest:

Attest:
Signature of President, Chief Financial Officer or Vice
President
Signature of Cashier, Treasurer, or Secretary

By
President, Chief Financial Officer or Vice President

Cashier, Secretary, or Treasurer

NOTE: One of the signers of the form must be listed on the bank's Official Authorization List (OAL) that is on file with the Federal Reserve
and hold one of the titles identified. It is recommended that banks periodically review and update this form. Instructions for submitting
Board Resolution and Authorized Approver packages are available online at https://www.frbservices.org/forms/accounting/index.html.
This application should be sent to the FEDERAL RESERVE BANK of your district.
Public reporting burden for this collection of information is estimated to average 0.5 hours per response, including the time to gather and maintain data in the required form and to review
instructions and complete the information collection. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden to: Secretary, Board of Governors of the Federal Reserve System, Washington, DC 20551; and to the Office of Management and Budget, Paperwork Reduction Project (7100–
0042), Washington, DC 20503. The Federal Reserve may not conduct or sponsor, and an organization (or a person) is not required to respond to a collection of information unless it displays a currently valid OMB control number.
02/2022