Form FR MM-AC FR MM-AC Application for Conversion of a Mutual Holding Company t

DRAFT

FR MM-AC
OMB Number 7100-0335
Approval expires January 31, 20XX
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Board of Governors of the Federal Reserve System

Application for Conversion of a Mutual Holding Company to
Stock Form—FR MM – Form AC
The information in this form is required by law:
12 U.S.C. § 1467(o); 12 CFR Part 239 (Mutual Holding
Companies).

The Federal Reserve System (“FRS”) will use the information
specified in this form to review requests from mutual holding
companies to convert to stock form. 1

Name of Applicant
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

03/2015

1
Public reporting burden for this collection of information is estimated to average 60 hours per response, including the time to gather and maintain data in the required form, to review
instructions and to complete the information collection. The Board may not conduct or sponsor, and an organization is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. 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, 20th and C Streets, NW, Washington, DC 20551; and to the Office of Management and Budget, Paperwork
Reduction Project (7100-0121), Washington, DC 20503.

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

Name

Title/Organization

Title/Organization

Street Address

Street Address

City

State

Zip Code

City

Area Code / Phone Number

Area Code / Phone Number

Email Address

Email Address

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. 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 Board 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 Board or of the United States.

.
Year

Signature of Chief Executive Officer or Designee

Printed or Typed Name

Title

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