Form NCUA 3250 NCUA 3250 Application to Request Consent Pursuant to Section 205(d

OMB No. 3133-0203

NATIONAL CREDIT UNION ADMINISTRATION

APPLICATION TO REQUEST CONSENT PURSUANT TO SECTION 205(d)

OF THE FEDERAL CREDIT UNION ACT

PAPERWORK REDUCTION ACT NOTICE

The estimated average public reporting burden associated with this information collection is 3 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 should be address to the National Credit Union Administration (NCUA), ATTN: NCUA PRA Clearance Officer, 1775 Duke Street, Alexandria, Virginia 22314.  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. 

PRIVACY ACT STATEMENT

Authority: 12 United States Code (U.S.C.) § 1785(d) (“Section 205(d)”)

Purpose: The NCUA will use the information provided on this form to evaluate your application for the NCUA Board’s consent to allow you to become or continue as an institution-affiliated party, or otherwise participate, directly or indirectly, in the conduct of the affairs of an insured credit union.

Routine Uses: This form may be disclosed to render legal advice, as part of judicial or administrative proceedings, to appropriate Federal or State credit union regulatory agencies and law enforcement or other governmental agencies if relevant to processing or necessary for administrative reasons or otherwise. Information from this form will be provided to the Federal Bureau of Investigation to receive your criminal history record. A complete list of Routine Uses is available at www.ncua.gov/privacy.

Effects of Not Providing Information: Failure to complete this form or omission of any item of information may result in a delay in the processing of this application.

SORN: NCUA-26, Prospective Official Application Records, 88 FR 22486

Section 205(d)(1) of the Federal Credit Union Act, 12 U.S.C. §1785(d)(1), generally provides that, except with the prior written consent of the National Credit Union Administration Board (Board), a person who has been convicted of any criminal offense involving dishonesty or breach of trust, or has agreed to enter into a pretrial diversion or similar program in connection with a prosecution for such offense may not become, or continue as an institution-affiliated party with respect to any insured credit union; or otherwise participate, directly or indirectly, in the conduct of the affairs of any insured credit union.

Section 205(d)(1)(B) further provides that an insured credit union may not allow any person described above to engage in any conduct or to continue any relationship prohibited by Section 205(d). Section 205(d)(3) states that “whoever knowingly violates” (d)(1)(A) or (d)(1)(B) is committing a felony, punishable by up to 5 years in jail and a fine of up to $1,000,000 a day. The statute also prescribes a minimum 10-year prohibition period for certain offenses.

Part 752 of the NCUA’s regulations, 12 Code of Federal Regulations (C.F.R.) part 752, governs the policies and procedures for seeking the Board’s consent pursuant to Section 205(d). Part 752 replaces Interpretive Ruling and Policy Statement (IRPS) 19-1, entitled Exceptions to Employment Restrictions under Section 205(d) of the Federal Credit Union Act (“Second Chance IRPS”). Additionally, the NCUA prepared Section 205(d) guidance to assist credit unions and individuals in requesting the Board’s consent. Part 752 and the Section 205(d) guidance are accessible through the Regulatory and Compliance Resources page on the NCUA’s website.

All requests for the Board’s consent pursuant to Section 205(d) must be submitted using this application form (NCUA Form 3250). Please consult Part 752 prior to completing the application, as not all criminal convictions require an application to be submitted. Part 752 also describes the factors the Board will consider when evaluating any application for consent.

Any questions regarding the process to request the Board’s consent pursuant to Section 205(d), including whether an application is required, may be directed to the Office of General Counsel at 703-518-6540 or [email protected].

Completed applications must be sent to the appropriate NCUA field office. Consent applications filed by a credit union must be filed with the NCUA Regional Office where the credit union’s home office is located, or with the Office of National Examinations and Supervision for credit unions that office supervises. Consent applications filed by an individual must be filed with the NCUA Regional Office where the person lives. Contact information for the NCUA’s Central and Regional Offices is available on the Contact Us page on the NCUA’s website. States covered by each NCUA Regional Office are also listed on the website and in 12 C.F.R. §790.2.

For additional information on Section 205(d) and the process for applying for the Board’s consent, please visit NCUA.gov.

NATIONAL CREDIT UNION ADMINISTRATION

APPLICATION TO REQUEST CONSENT PURSUANT TO SECTION 205(d)

OF THE FEDERAL CREDIT UNION ACT

INSTRUCTIONS: For applications sponsored by an insured credit union, SECTIONS I, II, IV, V, VI, and VII must be completed. For individual applications, SECTIONS IV, V, and VI must be completed. Both insured credit union sponsors and individual applicants must review SECTION III. If the application involves more than one covered offense, additional copies of SECTION V or additional pages labeled as “SECTION V” must be submitted for each covered offense. If more space is needed for any response, additional pages labeled with the applicable SECTION number may be submitted as an attachment.

Type of Application:  Credit union-sponsored  Individual

NOTE: An application may be filed by an individual on their own behalf or by an insured credit union on behalf of a person.

STATEMENT OF AUTHORIZATION: I/We have, in connection with preparing this application, read Section 205(d)(1) & (3) of the Federal Credit Union Act, 12 U.S.C. §1785(d)(1) & (3) and Part 752 of the NCUA’s regulations, 12 C.F.R. part 752, which govern requests by insured credit unions for the consent of the NCUA Board for a person who has been convicted of a crime involving dishonesty or breach of trust, or who has agreed to enter into a pretrial diversion or similar program in connection with a prosecution for such offense, to become or continue as an institution-affiliated party, or otherwise participate, directly or indirectly, in the conduct of the affairs of an insured credit union.

In support of this application, the following statements, representations and information are submitted for the purpose of inducing the NCUA Board to grant its written consent to the person identified below (the covered individual), who has been convicted of a crime involving dishonesty or breach of trust or has agreed to enter into a pretrial diversion or similar program in connection with a prosecution for such offense, to become or continue as an institution-affiliated party, or otherwise participate, directly or indirectly, in the conduct of the affairs of this credit union.

 I/We agree with the above statement and authorize the NCUA to process this application for the NCUA Board’s consent pursuant to Section 205(d) of the Federal Credit Union Act.

SECTION I – INSURED CREDIT UNION INFORMATION

1. Name of Insured Credit Union: 2. Charter Number: 3. Date of Application:

4. Address (Street, City, County, State, and ZIP Code): 5. Telephone:

6. Name of Credit Union Contact: 7. Contact Email:

SECTION II – POSITION TO BE OCCUPIED BY THE COVERED INDIVIDUAL IF THEY ARE A PROSPECTIVE DIRECTOR, OFFICER, OR EMPLOYEE

8. Title of Position(s) or Prospective Position(s):

9. Describe the duties and responsibilities of the prospective director, officer, or employee. Include the extent of supervision exercised, or potentially exercised, over others and/or by others:

SECTION III - NOTIFICATION OF FIDELITY INSURER

The insured credit union’s fidelity insurer is to be notified of all pertinent information regarding the conviction of the prospective employee. Assurances from the fidelity insurer must be obtained, in writing, stating that the prospective director, officer, or employee will be covered by the insured credit union’s fidelity bond. This application and the information requested herein may be submitted prior to notification of the bonding company. However, the NCUA Board’s consent will be subject to a condition that written assurance of fidelity coverage to the same extent as others in similar positions be obtained by the insured credit union.

ACKNOWLEDGMENT AND CERTIFICATION OF FIDELITY NOTIFICATION: I/We do hereby certify that I have read, understand, and agree to the above notification of fidelity insurer.

 I/We agree with the above acknowledgment and certification.

NOTE: The Biographical Information of the Covered Individual (Section IV) and Information Relative to Conviction(s) or Pretrial Diversion or Similar Program(s) (Section V) should be completed by the covered individual.

SECTION IV - BIOGRAPHICAL INFORMATION OF THE COVERED INDIVIDUAL

NOTE: In addition to a completed NCUA Form 3250 (Rev. 9/24), fingerprinting will be required to enable the NCUA to obtain the covered individual’s criminal history record (identity history summary check) from the Federal Bureau of Investigation (FBI). Additional documentation and instructions for the completion of the fingerprinting process will be provided by the applicant’s respective NCUA field office. It is not necessary for the covered individual to request their own criminal history record from the FBI. Once the NCUA obtains the covered individual’s FBI criminal history record, the NCUA field office will provide such record to the applicant to review for accuracy. The NCUA will not provide it to the credit union, but only to the individual who is the subject of the application. Further, other items may be requested and will be identified in the application or sought on a case-by-case basis.

10. Name of Covered Individual: 11. Date of Application:

12. Address (Street, City, State, ZIP Code):

13. Telephone: 14. Email:

15. Date of Birth: 16. Place of Birth:

SECTION V - INFORMATION RELATIVE TO CONVICTION(S) OR PRETRIAL DIVERSION OR SIMILAR

PROGRAM(S)

NOTE: If the Applicant is subject to more than one covered offense, attach additional pages labeled as “SECTION V,” and provide all the information relative to the conviction(s) or pretrial diversion or similar program(s).

17. Title and Citation of Covered Offense:

18. Date of Conviction or Date of Pretrial Diversion or Similar Program Entry:

19. Date of Sentencing:

20. Name and Address of Court (Street, City, State, ZIP Code):

21. Case Disposition:

NOTE: This application covers only those convictions or entry into pretrial diversion, or similar programs listed in this Section. If additional convictions or completion of pretrial diversion or similar programs for crimes involving dishonesty or breach of trust are discovered after an approval of this request, the applicant will be prohibited by Section 205(d) from participating in the affairs of an insured credit union. A subsequent application pursuant to Section 205(d) will be required.

22. Briefly describe the nature of the offense and the circumstances surrounding it. Include age of the individual at the time of the actions that resulted in the conviction or program entry, date the offense occurred, and any mitigating circumstances (parole, suspension of sentence, pardon, etc.):

23. Briefly describe the extent of rehabilitation of the covered individual and attach supporting documents, if any (e.g., resume, school transcripts). Evidence of an individual’s rehabilitation may include:

• Job description/description of duties and responsibilities of position to be occupied (Optional but recommended).

• Character reference letters (Optional but recommended).

• Resume at least covering the period since the covered offense (Optional but recommended).

• Documentation of educational achievements, in particular any since the covered offense (If applicable, optional but recommended).

• Documentation of successful participation in job preparation programs (If applicable, optional but recommended).

• Certificates documenting participation in substance abuse programs (If applicable, optional).

• Recent employment records/employee performance reviews (Optional).

• List of involvement in any charitable, community service, or other civic activities (Optional).

Please provide contact information for any individuals who may be contacted to verify evidence of rehabilitation for each item you wish to have considered as evidence of your rehabilitation, if appropriate (Optional).

NOTE: References have greater weight when the party providing the reference is aware of the individual’s prior history.

24. List and attach copies of the Indictment, Information, or Complaint and Final Decree of Judgment, or documentation to support the completion of a Pretrial Diversion or Similar Program, if available (Optional):

25. List any other pertinent facts relative to the offense that are not disclosed in the Indictment, Information, or Complaint and Final Decree of Judgment, if desired (Optional):

NOTE: In reviewing a consent application, the NCUA will primarily rely on the criminal history record of the FBI. The NCUA will not require an applicant to provide certified copies of criminal history records unless the NCUA determines that there is a clear and compelling justification to require additional information to verify the accuracy of the criminal history record of the FBI.

SECTION VI - ACKNOWLEDGEMENT OF COVERED INDIVIDUAL

NOTE: The information requested in Sections IV and V above is solicited pursuant to Section 205(d) of the Federal Credit Union Act (12 U.S.C. §1785). This information is necessary to assist the NCUA in assessing the merits of the application. Some of the information may be provided to any appropriate Federal or State insured credit union regulatory agency and the FBI or other law enforcement or governmental agencies for identity verification purposes. Should the information indicate a violation of law, the application may be referred to any agency responsible for investigating or prosecuting such a violation. In addition, in the event of litigation, the application may be presented to the appropriate court as evidence and to counsel during discovery. While submission of the information is voluntary, an omission or inaccuracy may result in a delay in processing the application, a return of the application as incomplete, or a denial of the application. Falsification of any of the information may serve as a basis for denial of the application or the removal of the director, officer, or employee if employed by the insured credit union as well as grounds for criminal charges.

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual or handwritten signature.

26. Name of Covered Individual: 27. Date:

ACKNOWLEDGMENT AND CERTIFICATION OF COVERED INDIVIDUAL: I do hereby certify that the Biographical Information (Section IV) and Information Relative to Conviction(s) or Pretrial Diversion or Similar Program(s) (Section V) are true and correct to the best of my knowledge and belief. I understand that the NCUA may conduct extensive checks into my background, experience, and related matters in conjunction with my application. I consent to and authorize the FBI or other law enforcement agencies, collection agencies, credit bureaus, consumer reporting agencies, and other sources of information to provide information about me including, but not limited to, financial, credit, tax, immigration, and criminal investigative information to the NCUA for the purpose of making a determination as to whether I have demonstrated my fitness to participate in the conduct of the affairs of an insured credit union, and whether my employment, affiliation, or participation in the conduct of the affairs of the credit union, may constitute a threat to the safety and soundness of the credit union or the interests of its members or threaten to impair public confidence in the credit union.

­­­ I agree with the above acknowledgment and certification.

SECTION VII – INSURED CREDIT UNION CERTIFICATION FOR APPLICATION

NOTE: This Section should be completed by the insured credit union for a credit-union sponsored application only.

28. Insured credit union may list any other additional information or provide testimony in support of this application, if appropriate (Optional):

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual or handwritten signature.

29. Name and Title of Credit Union Representative: 30. Date:

CERTIFICATION FOR APPLICATION: I do hereby certify that I am authorized to make applications pursuant to Section 205(d) of the Federal Credit Union Act on behalf of the insured credit union sponsoring the applicant listed in Section IV.

 I agree with the above certification for application.

This is an official document of the National Credit Union Administration. Providing false informtion may be grounds for prosecution under the provisions of Title 18, Section 1001 of the United States Code and may be punishable by fine or imprisonment.

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NCUA Form 3250 (Rev. 9/24)