Appointive Directo Federal Home Loan Bank Appointive Director Annual Certif

FEDERAL HOME LOAN BANK APPOINTIVE
DIRECTOR ANNUAL CERTIFICATION FORM

Your name: __________________________________________________________________
Federal Home Loan Bank of: ____________________________________________________
Every year, each incumbent appointive Federal Home Loan Bank (Bank) director must certify
that he or she continues to meet all of the following eligibility requirements:
•
•

•

•

United States citizen
Bona fide resident of a state within the geographic district of the Bank on whose board you
serve
o your principal residence is located within that geographic district OR
o you own or lease a second residence within the district and are employed within the
district
During your term of office, you may not:
o serve as an officer of any Federal Home Loan Bank
o serve as an officer or director of any member or subsidiary of a member of the Bank you
serve, or any holding company that controls one or more members of the Bank you serve
if the assets of all such members constitute 35 percent or more of the assets of the holding
company, on a consolidated basis
o hold shares of stock or have any other financial interest in any member or subsidiary of a
member of the Bank you serve, or any holding company that controls one or more
members of the Bank you serve if the assets of all such members constitute 35 percent or
more of the assets of the holding company, on a consolidated basis
o have contractual rights to the payment of money from a member, a subsidiary of a
member, or a holding company that controls one or more members of the Bank you
serve, if the amount due in a calendar year constitutes 10 percent or more of your
adjusted gross income for that calendar year
To be designated a community interest director, you must come from an organization with
more than a two-year history of representing consumer or community interests on banking
services, credit needs, housing, or financial consumer protections
By executing this form, you are certifying that you continue to meet these
requirements and that the Appointive Director Application Form you
previously submitted as amended by any Annual Certification Form, is true,
correct, and complete to the best of your knowledge.

Page 1 of 2
Expires 11/30/2007
OMB No. 3069-0002

Please check one box:

No changes have occurred.
Changes have occurred to my responses in these sections of my Form:
Personal information:

Eligibility information, including conflicts of interest:

Commitment to serve:

Personal integrity:

Independence:

Other changes:

Dated: ___________________________________
Signature: ____________________________________________________________________
Page 2 of 2
Expires 11/30/2007
OMB No. 3069-0002