Form FDIC-2120/16 Applicant Certification Statement

OMB Number: 3064-0121
Expiration Date: 02/28/2025

Federal Deposit Insurance Corporation

APPLICANT CERTIFICATION STATEMENT

FRAUD OR FRAUDULENT STATEMENT NOTICE
Falsification of an answer may result in a fine of not more than $10,000 or imprisonment for not more than five (5) years
or both (18 U.S.C. §1001).

PRIVACY ACT STATEMENT
The FDIC is authorized to request this information from you by 12 U.S.C. §§ 1819, 1820, 1822(f); and Executive Order
9397 as amended. The FDIC will use this information to determine your eligibility for employment with the FDIC.
Furnishing the requested information is voluntary, but failure to provide the requested information in whole or in part may
delay or prohibit any further consideration of you for employment with the FDIC. The information you provide may be
provided to appropriate Federal, state, local or foreign agencies and law enforcement authorities; to a court,
administrative tribunal, or a party in litigation; and to contractors, agents and other third parties as authorized by law and
in accordance with any of the other routine uses described in the FDIC Personnel Records (FDIC-015) System of
Records available at https://www.fdic.gov/policies/privacy/documents/fdic-15-personnel-records.pdf. If you have
questions or concerns about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at
[email protected].

ESTIMATED REPORTING BURDEN
Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to the Paper Reduction Act
Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17th Street, N.W., Washington, DC 20429;
and to the Office of Management and Budget, Paperwork Reduction Project (3064-0121), Washington, D.C. 20503. An
agency may not conduct nor sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number.
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FDIC 2120/16 (12-24)

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OMB Number: 3064-0121
Expiration Date: 02/28/2025

Federal Deposit Insurance Corporation

APPLICANT CERTIFICATION STATEMENT
Federal Deposit Insurance Corporation Certification of Compliance with Section 12(f)(4) of the Federal Deposit Insurance Act (12
U.S.C. § 1822(f)(4)) as amended by Section 19 of Public Law 103-204.
NAME

SOCIAL SECURITY NUMBER (Last 4 digits)

NOTICE: If you wish to discuss any of the definitions or questions on this form prior to submission you may seek guidance from the
Ethics Unit, Legal Division, telephone (202) 898-8600.
The Federal Deposit Insurance Corporation (FDIC) is prohibited by statute from employing any person who does not meet minimum
competence, experience, integrity, and fitness requirements. No person shall become employed performing the responsibilities of or
for the FDIC who must respond YES to any of the following questions. Further, you are advised that the FDIC cannot retain
employees who are not in compliance with the prohibitions listed in Part I, below, anytime after June 17, 1994.

PART I - EMPLOYMENT REQUIREMENTS (Definitions provided on Page 3)
YES

NO

1. Have you been convicted of a felony?...............................................................................................................
2. Have you been removed from, or prohibited from participating in the affairs of, any insured depository
institution(s) pursuant to any final enforcement action by any federal banking agency?..................................
3. Have you demonstrated a pattern or practice of defalcation regarding obligations to insured depository
institutions?........................................................................................................................................................
4. Have you caused a substantial loss to federal deposit insurance funds?.........................................................
5. Are you aware of, or have any reason to believe, that you are under investigation or indictment for any
conduct, either criminal or civil, related to your employment at a Failed Financial Institution or an affiliated
entity of a Failed Financial Institution?..............................................................................................................

PART II - INFORMATION ON DEFAULTS
Any candidate for employment shall submit a list and description of all instances during the five (5) years preceding the submission of
an application for employment in which the person or a company under such person's control defaulted on a material obligation
aggregate in excess of $50,000 or more to an insured depository institution. Provide complete information regarding any default,
including the total dollar amount, financial institution, dates, and final judgment or current status of the obligation on a separate page.
Attach in duplicate and include your name, Social Security Number and original signature on each page of the attachment. You must
respond to all of the applicable boxes below.

YES

NO

1. I have defaulted on a material obligation or caused any loss as defined on page 3 within the last 5 years. If
yes, I have attached details regarding these defaults.......................................................................................
2. I have defaulted on a debt or duty to pay money (including any guaranty) owed to the FDIC or any Failed
Financial Institution within the last 5 years to such an extent that a judgment has been rendered in favor of
the FDIC or that the property securing the debt has been foreclosed on. If yes, I have attached details
regarding these defaults...................................................................................................................................

PART III - CERTIFICATION
I certify that I have read the definitions, which are a part of this form, and that the statements I have made on this certification are true,
complete, and correct to the best of my knowledge and belief. During the term of any employment I may have with the FDIC, I will
immediately provide the Ethics Unit with a written explanation of any facts or circumstances which would cause these answers to
change. Further,
If I become aware of, or am notified that I am a target of an investigation for any conduct, either criminal or civil, related to my
employment at a Failed Financial Institution or an affiliated entity of a Failed Financial Institution, I acknowledge that I must
immediately notify the FDIC pending consideration of my employment application or if selected for employment, prior to the
commencement of and during my employment with FDIC.
I understand that failure to notify FDIC of any current or pending investigations, indictments or convictions against me relating to
any of the above statements, or any false statements regarding this certification, could serve as the basis for action to be initiated
against me, ranging from withdrawal of the offer of employment, up to and including removal from the Federal service.
Applicant's Signature (Sign in Ink)

FDIC 2120/16 (12-24)

Date

Identify Announcement Number for which you have applied, or
Position Title, Grade, and Organizational Location:

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OMB Number: 3064-0121
Expiration Date: 02/28/2025

DEFINITIONS
1. “Felony” is any violation of law punishable by imprisonment of longer than one year, except for violations called
misdemeanors under state law which are punishable by imprisonment of two years or less.
2. “Company” is any individual, corporation, partnership, joint venture, business trust, association or similar organization, or any
other trust unless by its terms it must terminate within 25 years or not later than 21 years and ten months after the death of
individuals living on the effective date of the trust, but shall not include any corporation the majority of the shares of which are
owned by the United States, any state, or the District of Columbia.
3. “Control” means:
a. The power to vote, directly or indirectly, 25 percent or more of any class of the voting stock of a company, the ability
to direct in any manner the election of a majority of a company's directors or trustees, or the ability to exercise a
controlling influence over the company's management and policies. For purposes of this definition, a general partner
of a limited partnership is presumed to be in control of that partnership.
b. An entity or individual shall be presumed to have control of a company if the entity or individual directly or indirectly,
or acting in concert with one or more entities or individuals, or through one or more subsidiaries, owns or controls 25
percent or more of its equity, or otherwise controls or has power to control its management or policies.
4. "Default on material obligation" is a loan or advance from an insured depository institution which is or has been delinquent for
90 or more days as to payment of principal and/or interest.
5. “Insured depository institution” is any bank or savings association the deposits of which are insured by a Federal Deposit
Insurance Fund administered by the FDIC.
6. “Pattern or Practice of Defalcation regarding obligations” means:
a. A history of financial irresponsibility with regard to debts owed to insured depository institutions which are in default
in excess of $50,000 in the aggregate. Examples of such financial irresponsibility include, without limitation:
1. Failure to pay a debt or debts totaling more than $50,000 secured by an uninsured property which is
destroyed; or
2. Abuse of credit cards or incurring excessive debt well beyond the individual's ability to repay resulting in
default(s) in excess of $50,000 in the aggregate.
b. Wrongful refusal to fulfill duties and obligations to insured depository institutions. Examples of such wrongful refusal
to fulfill duties and obligations include, without limitation:
1. Any use of false financial statements;
2. Misrepresentation as to the individual's ability to repay debts;
3. Concealing assets from the insured depository institution;
4. Any instance of fraud, embezzlement or similar misconduct in connection with an obligation to the insured
depository institution; or
5. Any conduct described in any civil or criminal judgment against an individual for breach of any obligation,
contractual or otherwise, or any duty of loyalty or care that the individual owed to an insured depository
institution.
7. “Pattern or Practice of Defalcation regarding obligations” means:
a. A loan or advance from an insured depository institution, which is now owed to the Federal Deposit Insurance
Corporation (FDIC), Resolution Trust Corporation (RTC), Federal Savings Loan Insurance Corporation (FSLIC) or
their successors, or any Federal deposit insurance fund, that is delinquent for ninety (90) or more days as to
payment of principal, interest, or a combination thereof and on which there remains a legal obligation to pay an
amount in excess of $50,000;
b. A final judgment in excess of $50,000 in favor of any Federal deposit insurance fund, the FDIC, RTC, or FSLIC, or
their successors regardless of whether it becomes forgiven in whole or in part in a bankruptcy proceeding;
c. For purposes of computing the $50,000 ceiling above, all delinquent judgments, loans, or advances currently owed
to the FDIC, RTC, FSLIC, or their successors, or any Federal deposit insurance fund, shall be aggregated. In no
event shall delinquent loans or advances from different insured depository institutions be separately considered.

FDIC 2120/16 (12-24)

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