Form FR MM-PS FR MM-PS Proxy Statement

FR MM-PS
OMB Number 7100-0340
Approval expires July 31, 2023
Page 1 of 2

Board of Governors of the Federal Reserve System

Proxy Statement—FR MM-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.

Docket Number:

Date:
Month / Day / Year

NOTICE OF MEETING

Date (MM/DD/YYYY)

Time (AM/PM)

Vote Entitlement Date (MM/DD/YYYY)

Location:
Name of Applicant
Street Address
Street Address
City
City

State

Zip Code

State

Zip Code

Description:

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

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.

03/2023

FR MM-PS
Page 2 of 2

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

Signed this

day of
Day

,
Month

by the applicant or the individual, submitted in accordance with
the Instructions to this form and the Board's Rules Regarding
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

02/2020