March 2021 - Form 4501A - DRAFT

NATIONAL CREDIT UNION ADMINISTRATION
ALEXANDRIA, VIRGINIA 22314-3428
OFFICIAL BUSINESS

Credit Union Profile Form

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TO THE BOARD OF DIRECTORS OF THE CREDIT UNION ADDRESSED:
This booklet contains the Form 4501A Profile. The effective date of this form is
March 31, 2021 and will remain in effect until superseded. Instructions and
quarterly filing dates are available on the NCUA’s website at www.ncua.gov.

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The Profile Reporting Instructions page contains the filing requirements. Please
note, the Profile must be certified in conjunction with the filing of the Form 5300
Call Report.

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The NCUA website provides the quarterly filing date. In addition, credit union
contacts of record will continue to receive quarterly email notifications of the
cycle highlights.
If you have any questions, please contact your National Credit Union
Administration Regional Office or your state credit union supervisor, as
appropriate. Please direct any technical questions to NCUA Technical Support
at 1-800-827-3255.

OMB No. 3133-0204

NCUA Profile Form 4501A
Effective March 31, 2021
Previous Editions Are Obsolete

Report Date:_____________
Federal Charter/Certificate Number: ____________

Credit Union Name:___________________
Reporting Requirements

Provide Updated Information: In accordance with NCUA regulations part 741, insured credit unions are required to update their profile
information within 10 days of the election or appointment of senior management and volunteer officials, or within 30 days of any change.

Records Retention: Credit unions should retain a copy of the information used to complete the profile as a part of the permanent records of
the credit union.
The instructions to prepare this form meet the requirement to provide guidance to small credit unions under Section 212 of the Small
Business Regulatory Enforcement Fairness Act of 1996.

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Paperwork Reduction Act Statement
The estimated average public reporting burden associated with this information collection is 2 hours per response. Comments concerning
the accuracy of this burden estimate and or any other aspect of this information collection, including suggestions for reducing this burden to
should be addressed to the:
National Credit Union Administration
Office of General Counsel
Attn: PRA Clearance Officer
1775 Duke Street
Alexandria, VA 22314-3428

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An agency may not conduct or sponsor, and a person is not required to respond to, an information collection unless it displays a valid OMB
control number.

OMB No. 3133-0204

NCUA Profile Form 4501A
Effective March 31, 2021
Previous Editions Are Obsolete

Report Date: __________
Federal Charter/Certificate Number:___________

Credit Union Name:___________________
Certification

I understand each operating insured credit union must update their credit union profile within 10 days after the election or appointment of
senior management or volunteer officials, or within 30 days of any change of the information in the profile. I hereby certify to the best of my
knowledge and belief the information provided is current and accurate. I make this certification pursuant to sections 106, 120, and 204 of the
Federal Credit Union Act (12 U.S.C. 1756, 1766, and 1784).

Certified By

Last Name:

First Name:

Full Name :

Please Print

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Certified Correct By

Date:

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Certified Correct By (Signature)

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Previous Editions Are Obsolete

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Report Date: __________
Federal Charter/Certificate Number:___________

Credit Union Name:___________________

Certify Compliance
Minimum Security Devices and Procedures - NCUA Regulations Part 748
Federally Insured Credit Unions Only
I hereby certify to the best of my knowledge and belief that this credit union has developed and administers a security program that equals or
exceeds the standards prescribed by part 748.0 of the NCUA regulations; that such security program has been reduced to writing, approved
by this credit union's Board of Directors; and this credit union has provided for the installation, maintenance, and operation of security devices,
if appropriate, in each of its offices. Further, I certify that I am the president or managing official of the credit union or that the president or
managing official has authorized me to make this submission on his/her behalf.

Last Name:

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Certified By

First Name:

Job Title :
Please Print

Full Name :

Date:

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Certified By (Please Print)

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Certified By (Signature)

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Report Date: ______________
Federal Charter/Certificate Number:___________

Credit Union Name:___________________
General Information
1. Select the type of credit committee the credit union has:
a. Elected

b. Appointed

c. No Committee

2. Provide the credit union's Employer Identification Number (EIN) :
3. Provide the Research Statistics Supervision and Discount (RSSD) ID number issued by
the Board of Governors of the Federal Reserve System.
4. Is your credit union a member of the Federal Home Loan Bank?
a. Yes

b. No

5. Has your credit union filed an application to borrow from the Federal Reserve Bank Discount Window?
a. Yes

b. No

a. Yes

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6. Has your credit union pre-pledged collateral with the Federal Reserve Bank Discount Window?
b. No

7. Does your credit union sponsor a qualified defined benefit plan?
a. Yes

b. No

8. Does your credit union participate in a multiemployer defined benefit plan?
b. No

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a. Yes

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NCUA Profile Form 4501A
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Report Date: ______________
Federal Charter/Certificate Number:___________

Credit Union Name:___________________
Contacts and Roles

The credit union must provide information for the Mandatory Job Titles and Mandatory Roles listed below. These individuals may be officials, volunteers, or
employees of the credit union. NCUA will not release information regarding mailing addresses, email addresses, phone numbers, and fax numbers to the
public. Please reference the Profile Instructions for additional guidance.

Provide information for the following:
Mandatory Job Titles
Manager or CEO
Board Chairperson
Board Vice Chairperson
Board Treasurer
Board Members

Mandatory Roles

Supervisory Committee Chairperson
Supervisory Committee Members
Credit Committee Chairperson
Credit Committee Members

Call Report Contact
Profile Contact
Primary Emergency Contact
Secondary Emergency Contact

Primary Patriot Act Contact
Secondary Patriot Act Contact
Third Patriot Act Contact (if applicable)
Fourth Patriot Act Contact (if applicable)

1. Salutation*
2. First Name*

4. Last Name*

3. Middle Initial

5. Job Titles - * Indicates the credit union is required to provide information for these mandatory job titles .
a. Manager or CEO*

b. Board Chairperson*

c. Board Vice Chairperson*

d. Board Secretary

e. Board Treasurer*

f.

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g. Supervisory Committee Chairperson*

Board Members*

h. Supervisory Committee Member*

i. Credit Committee Chairperson, if applicable*

j.

Credit Committee Member, if applicable*

k. Chief Financial Officer

l.

Chief Information Officer

m. Internal Auditor

n. Other

6. Roles - * Indicates the credit union is required to provide information for these mandatory roles .

b. General Credit Union Contact

c. Call Report Contact*

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a. Volunteer

d. Profile Information Contact*
f.

g. Third Patriot Act Contact, if applicable*

h. Fourth Patriot Act Contact, if applicable*

i. Primary Emergency Contact*

j.

Secondary Emergency Contact*

l.

Information Security Contact

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e. Primary Patriot Act Contact*

k. Credit Union Employee

Secondary Patriot Act Contact*

7. Credit Union Employment Type* - The credit union is required to provide the employment type for all Mandatory Job Titles and Roles .
a. Full-time

b. Part-time

c. Volunteer

8. Home Address Information* - The credit union is required to provide this information for all Mandatory Job Titles
Address Line 1:
Address Line 2:
City

State

Postal Code

Home email:
Home phone:

Home cell:

Home fax:

Home county:

9. Work Address Information - The credit union is required to provide a work phone number for all Mandatory Roles
Work email:
Work phone*:

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Work cell:

NCUA Profile Form 4501A
Effective March 31, 2021
Previous Editions Are Obsolete

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Report Date: ______________
Federal Charter/Certificate Number:___________

Credit Union Name:___________________
Sites

The section of the profile is a mandatory section and must include the following site types and site functions:
Site Types
· Corporate Office
· Branch Office(s)

Site Functions
· Vital Records Center
· Location of Records
· Disaster Recovery

Mandatory fields are identified with an asterisk (*). Please reference the instructions for additional guidance.
1. *Site Name:
2. *Operational Status:

a. Normal

b. Planned

c. Suspended - Emergency

3. *Site Type:

a. Corporate Office

b. Branch Office

c. Other (Please Specify)

4. *Is Main Office:

a. Yes

b. No

5. *Hours of Operation:
Address Line 1:
Address Line 2:

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6. *Physical Address:

City / State / Postal Code:
County
7. *Mailing Address:

Country

Address Line 1:
Address Line 2:

County
Phone

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8. *Phone Numbers:

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City / State / Postal Code:

Country
Extension

Fax

9. *Site Function(s):

Non-Public Site Functions

in the Online Credit Union
Locator)

a. Disaster Recovery Location

h. Shared Service Center/Network

b. Location of Records

i. ATM

c. Vital Records Center

j. Drive Thru

d. Backup Generator

k. Member Services

e. Future Office
f. Hot Site
g. Planned Evacuation Site

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NCUA Profile Form 4501A
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Previous Editions Are Obsolete

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Report Date: ______________
Federal Charter/Certificate Number:___________

Credit Union Name:___________________

Payment System Service Provider Information (PSSP)
1. Select the credit union's Primary Settlement Agent (i.e., Member share draft clearing, ACH transactions, etc. -- See Instructions)
a. Federal Reserve Bank

b. CUSO

c. Corporate Credit Union

d. Federal Credit Union

e. Bank

f. Other Credit Union

g. Not Applicable
2. Provide the name of the primary payment systems service provider.
a. If other was selected, please specify
3. Identify the payment service(s) provided by the primary payment system service provider. (check all that apply)
a. Share Draft Processing and Settlement

b. Credit Card Processing and Settlement

c. Wire Transfers

d. ATM and Debit Processing and Settlement

e. Electronic Funds Transfer and Direct Deposit

f. Other

4. Have you changed payment system providers or plan to within the next 12 months?
a. Yes

b. No

5. Provide the name of the new provider :

a. Share Draft Processing and Settlement

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6. Identify payment service(s) affected by this change. (check all that apply)

d. ATM and Debit Processing and Settlement

b. Credit Card Processing and Settlement

c. Wire Transfers

e. Electronic Funds Transfer and Direct Deposit

f. Other

7. Systems used to process electronic payments (check all that apply)
a. Fedline Advantage
d. CUSO
g. EPN

b. Corporate Credit Union

c. Correspondent Bank

e. CHIPS

f. FedWire

h. Other (Please Specify)

a. Domestic

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8. If the credit union performs ACH transfers, are they domestic, international, or both? (check all that apply):
b. International

9. If the credit union is an Originating Depository Financial Institution, what types of ACH transactions are originated by the credit union? (check all that apply):
b. WEB - Internet Initiated/Mobile Entry

c. TEL - Telephone Initiated Entry

d. IAT - International ACH Transactions

e. Other Consumer Entry Codes

f. Other Business Entry Codes

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a. PPD - Prearranged Payment and Deposit Entry

10. If the credit union performs wire transfers, are they domestic, international, or both? (check all that apply):
a. Domestic

b. International

11. Which method(s) can a member use to initiate electronic payments (e.g. wire transfer, ACH, etc.) from the credit union (check all that apply):
a. Email

b. Fax

c. Online Banking

d. Telephone

e. In Person

f. Other (Please Specify)

Repeat Questions 1-3 for each Settlement Agent used.

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NCUA Profile Form 4501A
Effective March 31, 2021
Previous Editions Are Obsolete

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Report Date: ______________
Federal Charter/Certificate Number:___________

Credit Union Name:___________________

Information Technology (IT)
1. Does the credit union have a website?

a. Yes

b. No

a. Internal

b. External

a. Informational Website

b. Online Banking

a. Website Address :

2. Where is the website hosted ?
3. Provide the name of the external website vendor :
4. Select the type(s) service offered :

c. Mobile Application

5. If a credit union has online or mobile banking, how many members use it?
6. Which wireless networks, if any, does the credit union operate:
a. Public or Guest Network

b. Private or Restricted Network

7. Data Processing System used to maintain credit union records:
b. Vendor Supplied In-House System

c. Vendor Online Service Bureau

d. CU Developed In-house System

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a. Manual System

8. If the credit union has undergone or plans to undergo a Core Data Processing Conversion, please provide the following:
a. Date of Conversion:

b. Core Processor Converting/Converted to:

9. Name of the primary share/loan data processing vendor:

10. Select the service(s) the credit union offers electronically:

b. Bill Payment

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a. Account Aggregation

c. Download Account History

d. Electronic Signature Auth./Cert.

e. E-Statements

f. External Account Transfers

g. Loan Payments

h. Member Application

i. Merchant Processing

k. New Share Account

l. Remote Deposit Capture

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j. New Loan
m. Mobile Payments

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n. Other (Please Specify)

NCUA Profile Form 4501A
Effective March 31, 2021
Previous Editions Are Obsolete

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Report Date: ______________
Federal Charter/Certificate Number:___________

Credit Union Name:___________________
Regulatory Information
1. Please provide the date of the most recent annual meeting held by the credit union:
2. Please provide the date of the most recent financial statement audit:
3. Please select the last type of audit performed for the credit union's records:
a. Financial statement audit performed by state licensed persons
b. Balance sheet audit performed by state licensed persons

c. Examinations of internal controls over call reporting performed by state licensed persons
d. Supervisory Committee audit performed by state licensed persons
e. Supervisory Committee audit performed by other external auditors
f. Supervisory Committee audit performed by the supervisory committee or designated staff
4. Provide the name of the Audit Firm or Auditor (see instructions)
5. Please provide the effective date of the most recent Supervisory Committee verification of member's accounts :
a. Supervisory Committee

b. Third Party

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6. Please select who completed the verification of member's accounts:
7. Provide the date of the most recent Bank Secrecy Act Independent Test:

8. Provide your Supervisory Committee contact information for public/official correspondence

Mailing Address:_________________________________________ Email:____________________

Mailing City:_______________________________ State:___________ Zip Code:_______________
9. Indicate the Fidelity Bond Provider Name :

10. Indicate the amount of Fidelity Coverage for any Single Loss (RR 713.5):

11. Please provide Section 701.4 certification date (Federal Credit Unions Only):

Certification Date

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12. Please provide Section 701.4 certifier's name (Federal Credit Unions Only):

Certified By

13. Please provide Section 701.4 certifier's job title (Federal Credit Unions Only):
Job Title

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14. Does your credit union meet any of the following criteria? (Yes/No)
- Credit union with 100 or more employees; or
- Credit union with 50 or more employees and:
1) Has a contract of at least $50,000 with the Federal government; or
2) Serves as a depository of U.S. government funds of any amount; or
3) Serves as a paying agent for U.S. Savings Bonds.
a. If yes, what is the last date you filed an EEO-1 Survey Report with the U.S. Equal Employment Opportunity Commission (MM/DD/YYYY)?
b. If yes, do you have a diversity policy and/or program in your credit union? (Yes/No)
15. LIBOR Exposure:
a. Does your Credit Union have any member related transactions (for example loans or shares) indexed to LIBOR?
Yes

No

b. Does your Credit Union have any non-member or counterparty transactions (for example investments or derivatives) indexed to LIBOR?
Yes
No
16. List any trade names the credit union uses for signage or advertising.

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NCUA Profile Form 4501A
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Previous Editions Are Obsolete

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Report Date: ______________
Federal Charter/Certificate Number:___________

Credit Union Name:___________________

Disaster Recovery Information
1. In the event of a disaster, will the credit union communicate with members through a website ?
a. Yes

b. No

2. Please check the resources or services you have available and would be willing to share with other credit unions during the time of an emergency if you did
not need them. (Check all that apply)
a. Cash Non-Member Share Drafts

b. Generator

c. IT Support

d. Mobile Branch

e. Office Space

f. Staff/Management Services

3. Please provide the date of the last disaster recovery test completed by the credit union:
a. Indicate the method(s) used for the last disaster recovery test completed by the credit union.
3. Functional Testing

2. Tabletop/Mini-Drill

4. Full-Scale Testing

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1. Orientation/Walk Through

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Previous Editions Are Obsolete

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Report Date: ______________
Federal Charter/Certificate Number:___________

Credit Union Name:___________________

Credit Union Programs and Member Services
1. Credit Union Programs (Check all that apply)
a. Mortgage Processing

b. Deposits and Shares Meeting 703.10(a)

c. Approved Mortgage Seller

d. Brokered Certificates of Deposit

e. Brokered Deposits (all deposits acquired through a third party)

f. Investment Pilot Program (FCU Only)

Payday Alternative Loans (PALs I & II - FCU Only)
g. PALs I (FCU Only)

h. PALs II (FCU Only)

2. Member Service and Product Offerings (Check all that apply)
Consumer Initiated Remittance Transfers

a. Financial Counseling

a. International Remittances

b. Financial Education

b. Low-cost Wire Transfers

c. Financial Literacy Workshops

c. Proprietary remittance transfer services operated by the CU

d. First Time Homebuyer Program

d. Proprietary remittance transfer services operated by another person

e. Credit Management and Repair
f. Online Financial Literacy

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Financial Literacy Education

In-School Branches (If checked, specify number of branches)
a. Elementary School

Other Member Services and Products
a. No Cost Share Drafts

b. Middle School
c. High School

b. No Cost Bill Payer
c. No Cost Tax Preparation Services

Youth Savings Accounts/Programs

e. Student Scholarship
f. Credit Builder

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g. Bilingual Services

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d. Share Certificates with low minimum balance requirement

3. Shared Service Centers/Networks

a. Yes

a. Offer Custodial Accounts

b. Offer Non-Custodial Accounts

b. No

4. Payday Alternative Loans (PALs I and II loans) program (FCUs Only) - Place a "" in the associated box for all the credit union offers
(Check all that apply)

a. Credit Bureau Reporting
b. Financial Education
c. Forced Savings Component
d. Payroll Deduction

5. Minority Depository Institution Questions
Are more than 50% of your credit union’s current and eligible potential members Black American, Native American, Hispanic American, or Asian
American? If yes, please identify the minority group(s) that apply:
a. Black American

b. Hispanic American

c. Native American

d. Asian American

Is more than 50% of your credit union’s board of directors Black American, Native American, Hispanic American, or Asian American? If yes, please
identify the minority group(s) that apply:
a. Black American

b. Hispanic American

c. Native American

d. Asian American

OMB No. 3133-0204

NCUA Profile Form 4501A
Effective March 31, 2021
Previous Editions Are Obsolete

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Report Date: ______________
Federal Charter/Certificate Number:___________

Credit Union Name:___________________

Credit Union Grant Information
This page must be completed if the credit union receives grant funds.
Grant Information - Please provide information on any grants you have received since the last time you reported.

Grantor Type and Grantor

Date Awarded

Amount
Awarded

Grant Type*

Government (State, Local, Federal)
Community Development Financial Institution
Department of Education
Department of Health and Human Services
Federal Home Loan Bank
Housing and Urban Development
Internal Revenue Service
NCUA Technical Assistance Program
Small Business Administration

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US Department of Agriculture
Other (Please Specify):
Other (Please Specify):
Trade Associations
National Credit Union Foundation

National Federation of Community Development Credit Unions
Other (Please Specify):
Credit Unions and Banks

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Specify Name:

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State League Foundation

Specify Name:

Foundations (local and national)
Specify Name:
Specify Name:
*Grant Types:

a. Capital - unrestricted donation to equity
b. Subsidy for Risk or ALLL

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c. Program Grant
d. Pass Through

NCUA Profile Form 4501A
Effective March 31, 2021
Previous Editions Are Obsolete

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Report Date: ______________
Federal Charter/Certificate Number:___________

Credit Union Name:___________________
Merger Partner Registry

This page is optional for credit unions and not required to be completed. If this page is completed, the mandatory fields are identified with an asterisk (*).
This information will not be released to the public.
1. Is your credit union interested in expanding its Field Of Membership through a consolidation of another credit union?
a. Yes

b. No

If Yes, Please proceed to the remaining questions.
2. Please provide the name and phone number of the person at the credit union who can be contacted regarding any potential consolidations.
*Job Title :
*First Name :

*Last Name :

*Phone :

*Extension :

Anywhere in the United States

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3. Please identify the geographic areas in which the credit union would be interested. (Select only ONE Box)

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Anywhere within Selected States (Please specify states)

Specific Counties/Cities within a Selected State (Specify the state(s) on lines above)
State

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County/Counties

NCUA Profile Form 4501A
Effective March 31, 2021
Previous Editions Are Obsolete

City/Cities

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