Form FR MM-PS FR MM-PS Proxy Statement

FR MM-PS

PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS.

OMB Number 7100-0335
Approval expires January 31, xx
Page 1 of 2

DRAFT

Board of Governors of the Federal Reserve System

Proxy Statement—FR MM - Form PS

The information in this form is required by law: 12 CFR Part 239
(Mutual Holding Companies).
The Federal Reserve System will use the information specified in
this form to provide mutual members with information necessary
for voting on the transaction. 1

Docket Number:

Date:
Month / Day / Year

NOTICE OF MEETING
Name of Applicant

Date (MM/DD/YYYY)

Street Address of Applicant

Time (AM/PM)

Vote Entitlement Date (MM/DD/YYYY)

Location:
City

State

Zip Code
Street Address of Meeting Location

City

State

Zip Code

State

Zip Code

Description:

City

1
Public reporting burden for this collection of information is estimated to average 50 hours per response, including time to gather and maintain data in the required form and to review
instructions and complete the information collection. A Federal agency 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. Comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing the
burden, may be sent 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 (7100-0335), Washington, DC 20503.

07/2019

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

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 of Governors of the Federal
Reserve System (“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 CFR 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 Board 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 of Applicant

Print or Type Name

Title

07/2019