Profile form

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Overview

Cover
Changes
Instruct
Certification-1
Contacts (1)-2
Contacts (2)-3
Contacts (3)-4
Contacts (4)-5
Contacts (5)-6
Contacts (6)-7
Contacts (7)-8
Sites (1)-9
Sites (2)-10
Sites (3)-11
IST(1)-12
IST(2)-13
Reg-14
CUSO-15
Program_Svs-16
Grants-17

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Sheet 1: Cover

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Sheet 2: Changes

CREDIT UNION PROFILE CHANGES EFFECTIVE SEPTEMBER 2009

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Sheet 3: Instruct

INSTRUCTIONS FOR REPORTING REQUIREMENTS

This form has been divided into sections based on the categories in the online credit union profile. All credit unions must complete all sections if this is your first time filing this form with the National Credit Union Administration. Therefore, all credit unions receiving this form for September 30, 2009 Call Report cycle, must complete the entire form, as applicable and return it to the contact identified on the enclosed instructional letter.

For Call Report cycles after September 30, 2009: Credit unions that have submitted this information previously are only required to complete the areas that have changed since the last time they filed. If there are no changes to the area, please check the box titled "No changes".

All credit unions filing this form manually, must sign the certification page on page 1.

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Sheet 4: Certification-1

CERTIFICATION
Credit Union Name:		________________________________________________				Charter Number: _________
I understand each operating insured credit union must update their credit union profile within 30 days of any changes and certify its accuracy every 180 days in accordance with NCUA Rules and Regulations. I hereby certify to the best of my knowledge and belief the information in the profile has been updated and is accurate. I make this certification pursuant to sections 106, 120, and 204 of the Federal Credit Union Act (12 U.S.C. 1756, 1766, and 1784).
Last Name:	_________________________			First Name: _________________			Date:___________
Please Print	Certified Correct By
Full Name	________________________________________________
	Certified Correct By (Signature)
Last Name:	_________________________			First Name: _________________			Date:___________
Please Print	Prepared By
Full Name	________________________________________________
	Prepared By (Signature)

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Sheet 5: Contacts (1)-2

CONTACTS (1)
Credit Union Name:		________________________________________________				Charter Number: _________
There have been no changes to my contacts since the last time I completed this form
The Contacts section of the profile includes all of the Officials, Disaster Recovery Contacts, Emergency Contacts, Profile and 5300 Call Report contacts. Mandatory fields are identified with an asterisk (*). Please reference the directions for a list of all required contacts and roles the credit union must report.
A. *Job Title: Manager/CEO *CU Employment: ______________________
*Salutation:_____*First Name:________________Middle Initital:_____ *Last Name:___________________
Work Email:________________________________Home Email:______________________________
*Role(s) - See Instructions: _____________________________________________
*Home Address: _______________________________________________ *Country:_______________
*Home City:___________________________ *State:______*Zip Code: ___________
*Home Phone: ___________________ Fax:____________________ Cell Phone:_________________
Work Address: _______________________________________________ Country:__________________
Work City:_______________________________ State:_______ Zip Code: ____________
Work Phone: ________________ Extension: _____ Fax:______________ Cell Phone:______________
B. *Job Title: Chairperson *CU Employment: ______________________
*Salutation:_____*First Name:________________Middle Initital:_____ *Last Name:___________________
Work Email:________________________________Home Email:______________________________
*Role(s) - See Instructions: _____________________________________________
*Home Address: _______________________________________________ *Country:_______________
*Home City:___________________________ *State:______*Zip Code: ___________
*Home Phone: ___________________ Fax:____________________ Cell Phone:_________________
Work Address: _______________________________________________ Country:__________________
Work City:_______________________________ State:_______ Zip Code: ____________
Work Phone: ________________ Extension: _____ Fax:______________ Cell Phone:______________
C. *Job Title: Vice Chairperson *CU Employment: ______________________
*Salutation:_____*First Name:________________Middle Initital:_____ *Last Name:___________________
Work Email:________________________________Home Email:______________________________
*Role(s) - See Instructions: _____________________________________________
*Home Address: _______________________________________________ *Country:_______________
*Home City:___________________________ *State:______*Zip Code: ___________
*Home Phone: ___________________ Fax:____________________ Cell Phone:_________________
Work Address: _______________________________________________ Country:__________________
Work City:_______________________________ State:_______ Zip Code: ____________
Work Phone: ________________ Extension: _____ Fax:______________ Cell Phone:______________

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Sheet 6: Contacts (2)-3

CONTACTS (2)
Credit Union Name:		________________________________________________				Charter Number: _________
There have been no changes to my contacts since the last time I completed this form
D. *Job Title: Secretary *CU Employment: ______________________
*Salutation:_____*First Name:________________Middle Initital:_____ *Last Name:___________________
Work Email:________________________________Home Email:______________________________
*Role(s) - See Instructions: _____________________________________________
*Home Address: _______________________________________________ *Country:_______________
*Home City:___________________________ *State:______*Zip Code: ___________
*Home Phone: ___________________ Fax:____________________ Cell Phone:_________________
Work Address: _______________________________________________ Country:__________________
Work City:_______________________________ State:_______ Zip Code: ____________
Work Phone: ________________ Extension: _____ Fax:______________ Cell Phone:______________
E. *Job Title: Treasurer *CU Employment: ______________________
*Salutation:_____*First Name:________________Middle Initital:_____ *Last Name:___________________
Work Email:________________________________Home Email:______________________________
*Role(s) - See Instructions: _____________________________________________
*Home Address: _______________________________________________ *Country:_______________
*Home City:___________________________ *State:______*Zip Code: ___________
*Home Phone: ___________________ Fax:____________________ Cell Phone:_________________
Work Address: _______________________________________________ Country:__________________
Work City:_______________________________ State:_______ Zip Code: ____________
Work Phone: ________________ Extension: _____ Fax:______________ Cell Phone:______________
F. *Job Title: Board Member *CU Employment: ______________________
*Salutation:_____*First Name:________________Middle Initital:_____ *Last Name:___________________
Work Email:________________________________Home Email:______________________________
*Role(s) - See Instructions: _____________________________________________
*Home Address: _______________________________________________ *Country:_______________
*Home City:___________________________ *State:______*Zip Code: ___________
*Home Phone: ___________________ Fax:____________________ Cell Phone:_________________
Work Address: _______________________________________________ Country:__________________
Work City:_______________________________ State:_______ Zip Code: ____________
Work Phone: ________________ Extension: _____ Fax:______________ Cell Phone:______________

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Sheet 7: Contacts (3)-4

CONTACTS (3)
Credit Union Name:		________________________________________________				Charter Number: _________
There have been no changes to my contacts since the last time I completed this form
If the credit union has additional Board Members, please continue on a copy of this form.
G. *Job Title: Board Member *CU Employment: ______________________
*Salutation:_____*First Name:________________Middle Initital:_____ *Last Name:___________________
Work Email:________________________________Home Email:______________________________
*Role(s) - See Instructions: _____________________________________________
*Home Address: _______________________________________________ *Country:_______________
*Home City:___________________________ *State:______*Zip Code: ___________
*Home Phone: ___________________ Fax:____________________ Cell Phone:_________________
Work Address: _______________________________________________ Country:__________________
Work City:_______________________________ State:_______ Zip Code: ____________
Work Phone: ________________ Extension: _____ Fax:______________ Cell Phone:______________
H. *Job Title: Board Member *CU Employment: ______________________
*Salutation:_____*First Name:________________Middle Initital:_____ *Last Name:___________________
Work Email:________________________________Home Email:______________________________
*Role(s) - See Instructions: _____________________________________________
*Home Address: _______________________________________________ *Country:_______________
*Home City:___________________________ *State:______*Zip Code: ___________
*Home Phone: ___________________ Fax:____________________ Cell Phone:_________________
Work Address: _______________________________________________ Country:__________________
Work City:_______________________________ State:_______ Zip Code: ____________
Work Phone: ________________ Extension: _____ Fax:______________ Cell Phone:______________
I. *Job Title: Board Member *CU Employment: ______________________
*Salutation:_____*First Name:________________Middle Initital:_____ *Last Name:___________________
Work Email:________________________________Home Email:______________________________
*Role(s) - See Instructions: _____________________________________________
*Home Address: _______________________________________________ *Country:_______________
*Home City:___________________________ *State:______*Zip Code: ___________
*Home Phone: ___________________ Fax:____________________ Cell Phone:_________________
Work Address: _______________________________________________ Country:__________________
Work City:_______________________________ State:_______ Zip Code: ____________
Work Phone: ________________ Extension: _____ Fax:______________ Cell Phone:______________

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Sheet 8: Contacts (4)-5

CONTACTS (4)
Credit Union Name:		________________________________________________				Charter Number: _________
There have been no changes to my contacts since the last time I completed this form
J. *Job Title: Credit Committee Chairperson *CU Employment: ____________________
*Salutation:_____*First Name:________________Middle Initital:_____ *Last Name:___________________
Work Email:________________________________Home Email:______________________________
*Role(s) - See Instructions: _____________________________________________
*Home Address: _______________________________________________ *Country:_______________
*Home City:___________________________ *State:______*Zip Code: ___________
*Home Phone: ___________________ Fax:____________________ Cell Phone:_________________
Work Address: _______________________________________________ Country:__________________
Work City:_______________________________ State:_______ Zip Code: ____________
Work Phone: ________________ Extension: _____ Fax:______________ Cell Phone:______________
K. *Job Title: Credit Committee Member *CU Employment: ______________________
*Salutation:_____*First Name:________________Middle Initital:_____ *Last Name:___________________
Work Email:________________________________Home Email:______________________________
*Role(s) - See Instructions: _____________________________________________
*Home Address: _______________________________________________ *Country:_______________
*Home City:___________________________ *State:______*Zip Code: ___________
*Home Phone: ___________________ Fax:____________________ Cell Phone:_________________
Work Address: _______________________________________________ Country:__________________
Work City:_______________________________ State:_______ Zip Code: ____________
Work Phone: ________________ Extension: _____ Fax:______________ Cell Phone:______________
L. *Job Title: Credit Committee Member *CU Employment: _____________________
*Salutation:_____*First Name:________________Middle Initital:_____ *Last Name:___________________
Work Email:________________________________Home Email:______________________________
*Role(s) - See Instructions: _____________________________________________
*Home Address: _______________________________________________ *Country:_______________
*Home City:___________________________ *State:______*Zip Code: ___________
*Home Phone: ___________________ Fax:____________________ Cell Phone:_________________
Work Address: _______________________________________________ Country:__________________
Work City:_______________________________ State:_______ Zip Code: ____________
Work Phone: ________________ Extension: _____ Fax:______________ Cell Phone:______________

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Sheet 9: Contacts (5)-6

CONTACTS (5)
Credit Union Name:		________________________________________________				Charter Number: _________
There have been no changes to my contacts since the last time I completed this form
M. *Job Title: Supervisory Committee Chairperson *CU Employment:_________________
*Salutation:_____*First Name:________________Middle Initital:_____ *Last Name:___________________
Work Email:________________________________Home Email:______________________________
*Role(s) - See Instructions: _____________________________________________
*Home Address: _______________________________________________ *Country:_______________
*Home City:___________________________ *State:______*Zip Code: ___________
*Home Phone: ___________________ Fax:____________________ Cell Phone:_________________
Work Address: _______________________________________________ Country:__________________
Work City:_______________________________ State:_______ Zip Code: ____________
Work Phone: ________________ Extension: _____ Fax:______________ Cell Phone:______________
N. *Job Title: Supervisory Committee Member *CU Employment: ___________________
*Salutation:_____*First Name:________________Middle Initital:_____ *Last Name:___________________
Work Email:________________________________Home Email:______________________________
*Role(s) - See Instructions: _____________________________________________
*Home Address: _______________________________________________ *Country:_______________
*Home City:___________________________ *State:______*Zip Code: ___________
*Home Phone: ___________________ Fax:____________________ Cell Phone:_________________
Work Address: _______________________________________________ Country:__________________
Work City:_______________________________ State:_______ Zip Code: ____________
Work Phone: ________________ Extension: _____ Fax:______________ Cell Phone:______________
O. *Job Title: Supervisory Committee Member *CU Employment: __________________
*Salutation:_____*First Name:________________Middle Initital:_____ *Last Name:___________________
Work Email:________________________________Home Email:______________________________
*Role(s) - See Instructions: _____________________________________________
*Home Address: _______________________________________________ *Country:_______________
*Home City:___________________________ *State:______*Zip Code: ___________
*Home Phone: ___________________ Fax:____________________ Cell Phone:_________________
Work Address: _______________________________________________ Country:__________________
Work City:_______________________________ State:_______ Zip Code: ____________
Work Phone: ________________ Extension: _____ Fax:______________ Cell Phone:______________

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Sheet 10: Contacts (6)-7

CONTACTS (6)
Credit Union Name:		________________________________________________				Charter Number: _________
There have been no changes to my contacts since the last time I completed this form
This page is reserved so the credit union can report the name of their Chief Information Officer, Internal Auditor, Chief Financial Officer, and/or any of their employees or volunteers not already reported in the Contacts section of this form. This page is OPTIONAL. If you need additional lines, please continue on a copy of this form.
P. *Job Title: ___________________ *CU Employment: ______________________
*Salutation:_____*First Name:________________Middle Initital:_____ *Last Name:___________________
Work Email:________________________________Home Email:______________________________
*Role(s) - See Instructions: _____________________________________________
Home Address: _______________________________________________ Country:_______________
Home City:_____________________________________ State:______Zip Code: ___________
Home Phone: ___________________ Fax:____________________ Cell Phone:_________________
Work Address: _______________________________________________ Country:__________________
Work City:_______________________________ State:_______ Zip Code: ____________
Work Phone: ________________ Extension: _____ Fax:______________ Cell Phone:______________
Q. *Job Title: ___________________ *CU Employment: ______________________
*Salutation:_____*First Name:________________Middle Initital:_____ *Last Name:___________________
Work Email:________________________________Home Email:______________________________
*Role(s) - See Instructions: _____________________________________________
Home Address: _______________________________________________ Country:_______________
Home City:___________________________________ State:______Zip Code: ___________
Home Phone: ___________________ Fax:____________________ Cell Phone:_________________
Work Address: _______________________________________________ Country:__________________
Work City:_______________________________ State:_______ Zip Code: ____________
Work Phone: ________________ Extension: _____ Fax:______________ Cell Phone:______________
R. *Job Title: ___________________ *CU Employment: ______________________
*Salutation:_____*First Name:________________Middle Initital:_____ *Last Name:___________________
Work Email:________________________________Home Email:______________________________
*Role(s) - See Instructions: _____________________________________________
Home Address: _______________________________________________ Country:_______________
Home City:__________________________________ State:______Zip Code: ___________
Home Phone: ___________________ Fax:____________________ Cell Phone:_________________
Work Address: _______________________________________________ Country:__________________
Work City:_______________________________ State:_______ Zip Code: ____________
Work Phone: ________________ Extension: _____ Fax:______________ Cell Phone:______________

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Sheet 11: Contacts (7)-8

CONTACTS (7)
Credit Union Name:		________________________________________________				Charter Number: _________
There have been no changes to my contacts since the last time I completed this form
The credit union must identify the following contacts. These individuals may be Officials, volunteers, or employees of the credit union. This information will not be released to the public. Mandatory fields are identified with an asterisk (*). Please refer to the instructions for additional guidance.
A. *Role: Call Report Contact *Job Title: __________________*CU Employment:_____________________
*Salutation:______*First Name:_________________Middle Initital:____ *Last Name:__________________
Work Email:________________________________Home Email:______________________________
*Work Phone: ________________________ Extension:___________
B. *Role: Profile Information Contact *Job Title: ______________*CU Employment:____________________
*Salutation:______*First Name:_________________Middle Initital:____ *Last Name:__________________
Work Email:________________________________Home Email:______________________________
*Work Phone: ________________________ Extension:___________
C. *Role: Primary Patriot Act Contact *Job Title: ______________*CU Employment:___________________
*Salutation:______*First Name:_________________Middle Initital:____ *Last Name:__________________
*Work Email:________________________________ *Fax Number:____________________________
*Work Phone: ________________________ Extension:___________
D. *Role: Secondary Patriot Act Contact *Job Title: ______________*CU Employment:_________________
*Salutation:______*First Name:_________________Middle Initital:____ *Last Name:__________________
*Work Email:________________________________ *Fax Number:____________________________
*Work Phone: ________________________ Extension:___________
E. *Role: Primary Emergency Contact *Job Title: ________________*CU Employment:__________________
*Salutation:______*First Name:_________________Middle Initital:____ *Last Name:__________________
*Work or Home Email:_______________________________ Cell Phone:___________________________
*Work or Home Phone (please identify): ________________________ Extension:___________
F. *Role: Secondary Emergency Contact *Job Title: ______________*CU Employment:_________________
*Salutation:______*First Name:_________________Middle Initital:____ *Last Name:__________________
*Work or Home Email:_______________________________ Cell Phone:___________________________
*Work or Home Phone (please identify): ________________________ Extension:___________

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Sheet 12: Sites (1)-9

SITES (1)
Credit Union Name:		________________________________________________				Charter Number: _________
There have been no changes to my sites since the last time I completed this form
The Sites section of the profile includes all locations the credit union operates from, shared service centers, the Disaster Recovery location, Vital Records Center, Hot site, and location of records. Mandatory fields are identified with an asterisk (*). Please reference the instructions for additional guidance.
A. Identify the Main Office information in this section. Mandatory fields are identified with an asterisk.
*Site Type: Corporate Office *Site Name: _________________ *Site Function(s):__________________
*Is Main Office: Yes *Hours of Operation: _________________ *Operational Status: __________________
*Phone:____________________ Extension:________ Fax:_____________________
*Mailing Address: _______________________________________________ *Country:_______________
*Mailing City:______________________________ *State:________*Zip Code: ___________
*Physical Address: ___________________________________________ *Country:__________________
*Physical City:_______________________________ *State:________ *Zip Code: ____________
B. Identify the Disaster Recovery Location information in this section.
*Site Type: ____________ *Site Name: _________________ *Site Function(s): Disaster Recovery Location
*Is Main Office: No Hours of Operation: _________________ *Operational Status: __________________
*Phone:____________________ Extension:________ Fax:_____________________
Mailing Address: _______________________________________________ Country:_______________
Mailing City:______________________________ State:________ Zip Code: ___________
*Physical Address: ___________________________________________ *Country:__________________
*Physical City:_______________________________ *State:________ *Zip Code: ____________
C. Identify the Vital Records Center information in this section. (Required by Rules and Regs Part 749)
*Site Type: _______________ *Site Name: _________________ *Site Function(s): Vital Records Center
*Is Main Office: No Hours of Operation: _________________ *Operational Status: __________________
*Phone:____________________ Extension:________ Fax:_____________________
Mailing Address: _______________________________________________ Country:_______________
Mailing City:______________________________ State:________ Zip Code: ___________
*Physical Address: ___________________________________________ *Country:__________________
*Physical City:_______________________________ *State:________ *Zip Code: ____________
D. Identify the hot site for the credit union, if applicable.
*Site Type: ______________________ *Site Name: _________________ *Site Function(s): Hot Site
*Is Main Office: No Hours of Operation: ________________ *Operational Status: __________________
*Phone:____________________ Extension:________ Fax:_____________________
Mailing Address: _______________________________________________ Country:_______________
Mailing City:______________________________ State:________ Zip Code: ___________
*Physical Address: ___________________________________________ *Country:__________________
*Physical City:_______________________________ *State:________ *Zip Code: ____________

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Sheet 13: Sites (2)-10

SITES (2)
Credit Union Name:		________________________________________________				Charter Number: _________
There have been no changes to my sites since the last time I completed this form
Record on this page all the branch locations the credit union may have. A Shared Service Center may be considered a branch location. Please identify Shared Service Centers under the "Site Function" field. Mandatory fields are identified with an asterisk (*). Please reference the instructions for additional guidance. If you have more than 4 branch locations, please continue on page 11 or a copy of this form.
E. Identify branch location information in this section. Mandatory fields are identified with an asterisk.
*Site Type: Branch Office *Site Name: _________________ *Site Function(s):__________________
*Is Main Office: No *Hours of Operation: _________________ *Operational Status: __________________
*Phone:____________________ Extension:________ Fax:_____________________
Mailing Address: _______________________________________________ Country:_______________
Mailing City:______________________________ State:________Zip Code: ___________
*Physical Address: ___________________________________________ *Country:__________________
*Physical City:_______________________________ *State:________ *Zip Code: ____________
F. Identify branch location information in this section. Mandatory fields are identified with an asterisk.
*Site Type: Branch Office *Site Name: _________________ *Site Function(s):__________________
*Is Main Office: No *Hours of Operation: _________________ *Operational Status: __________________
*Phone:____________________ Extension:________ Fax:_____________________
Mailing Address: _______________________________________________ Country:_______________
Mailing City:______________________________ State:________ Zip Code: ___________
*Physical Address: ___________________________________________ *Country:__________________
*Physical City:_______________________________ *State:________ *Zip Code: ____________
G. Identify branch location information in this section. Mandatory fields are identified with an asterisk.
*Site Type: Branch Office *Site Name: _________________ *Site Function(s):__________________
*Is Main Office: No *Hours of Operation: _________________ *Operational Status: __________________
*Phone:____________________ Extension:________ Fax:_____________________
Mailing Address: _______________________________________________ Country:_______________
Mailing City:______________________________ State:________ Zip Code: ___________
*Physical Address: ___________________________________________ *Country:__________________
*Physical City:_______________________________ *State:________ *Zip Code: ____________
H. Identify branch location information in this section. Mandatory fields are identified with an asterisk.
*Site Type: Branch Office *Site Name: _________________ *Site Function(s):__________________
*Is Main Office: No *Hours of Operation: _________________ *Operational Status: __________________
*Phone:____________________ Extension:________ Fax:_____________________
Mailing Address: _______________________________________________ Country:_______________
Mailing City:______________________________ State:________ Zip Code: ___________
*Physical Address: ___________________________________________ *Country:__________________
*Physical City:_______________________________ *State:________ *Zip Code: ____________

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Sheet 14: Sites (3)-11

SITES (3)
Credit Union Name:		________________________________________________				Charter Number: _________
There have been no changes to my sites since the last time I completed this form
Record on this page all locations where the credit union maintains its records. Sections K and L are provided for the credit union to report vacant land, future office locations, planned evaculation site, ATM or other locations. Reporting of ATM locations is optional. Mandatory fields are identified with an asterisk (*). Please reference the instructions for additional guidance.
I. Identify the site where the credit union maintains its records.
*Site Type: _______________ *Site Name: _________________ *Site Function: Location of Records
*Is Main Office: _____ *Hours of Operation: ________________ *Operational Status: ________________
*Phone:____________________ Extension:________ Fax:_____________________
Mailing Address: _______________________________________________ Country:_______________
Mailing City:______________________________ State:________Zip Code: ___________
*Physical Address: ___________________________________________ *Country:__________________
*Physical City:_______________________________ *State:________ *Zip Code: ____________
J. Identify an additional site where the credit union maintains its records.
*Site Type: _______________ *Site Name: _________________ *Site Function: Location of Records
*Is Main Office: _____ *Hours of Operation: ________________ *Operational Status: ________________
*Phone:____________________ Extension:________ Fax:_____________________
Mailing Address: _______________________________________________ Country:_______________
Mailing City:______________________________ State:________ Zip Code: ___________
*Physical Address: ___________________________________________ *Country:__________________
*Physical City:_______________________________ *State:________ *Zip Code: ____________
K. Credit unions may identify any additional sites they may have in this section. See instructions.
*Site Type: _______________ *Site Name: _________________ *Site Function(s):__________________
*Is Main Office: No *Hours of Operation: _________________ *Operational Status: __________________
*Phone:____________________ Extension:________ Fax:_____________________
Mailing Address: _______________________________________________ Country:_______________
Mailing City:______________________________ State:________ Zip Code: ___________
*Physical Address: ___________________________________________ *Country:__________________
*Physical City:_______________________________ *State:________ *Zip Code: ____________
L. Credit unions may identify any additional sites they may have in this section. See instructions.
*Site Type: _______________ *Site Name: _________________ *Site Function(s):__________________
*Is Main Office: No *Hours of Operation: _________________ *Operational Status: __________________
*Phone:____________________ Extension:________ Fax:_____________________
Mailing Address: _______________________________________________ Country:_______________
Mailing City:______________________________ State:________ Zip Code: ___________
*Physical Address: ___________________________________________ *Country:__________________
*Physical City:_______________________________ *State:________ *Zip Code: ____________

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Sheet 15: IST(1)-12

INFORMATION SYSTEMS AND TECHNOLOGY (IS&T) (1)
Credit Union Name:_______________________________________						Charter Number: _________
There have been no changes to my IS&T information since the last time I completed this form
				Yes	No
1. Does the credit union have a website?
	a. If yes, what is the website address
	b. If yes, is the website hosted internally?
	1 = yes 2 = no
	c. If yes, please indicate the type of website (select only one)?
	1 = Informational 2 = Interactive 3 = Transactional
	d. If the credit union has a transactional website, please provide
	the name of the primary vendor used to deliver such services
2. If the credit union does not have a website and plans to add one in the future,
	a. Please provide a date
	b. Please identify the type of website
	1 = Informational 2 = Interactive 3 = Transactional
						Yes	No
3. Does the credit union have Internet access?
4. Does the credit union have an internal wireless network?
5. If the credit union has an organizational email address, please provide it.
6. Indicate in the box at the right the number of the statement below which best describes the system the credit
	union uses to maintain its share and loan records.
	1 = Manual System		2 = Vendor Supplied In-House System
	3 = Vendor On-Line Service Bureau			4 = CU Developed In-House System			5 = Other
7. Indicate the name of the primary share and loan information processing vendor
8. How do your members access/perform electronic financial services (select all that apply):
	a. Home Banking via Internet Website
	b. Audio Response/Phone Based
	c. Automatic Teller Machine (ATM)
	d. Mobile Banking
	e. Kiosk
	f. Other
9. What services do you offer electronically (select all that apply):
	a. Member Application				j. Download Account History
	b. New Loan				k. Electronic Cash
	c. Account Balance Inquiry				l. Account Aggregation
	d. Share Draft Orders				m. Internet Access Services
	e. New Share Account				n. e-Statements
	f. Loan Payments				o. External Account Transfers
	g. View Account History				p. Electronic Signature
	h. Internal Share Account Transfers				Authentication/Certification
	i. Bill Payment				q. Other (please specify)
10. What systems does the credit union use to process electronic payments (select all that apply)?
	a. Fedline Advantage
	b. Corporate Credit Union
	c. Correspondent Bank
	d. Other (please specify)

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Sheet 16: IST(2)-13

IS&T (2) and DATA PROCESSING CONVERSION
Credit Union Name: _______________________________						Charter Number: _________
There have been no changes to my IS&T information since the last time I completed this form
11. If the credit union is an Originating Depository Financial Institution, what type of ACH transactions are
	originated by the credit union (check all that apply):
	a. Consumer Transactions				e. TEL Based Transactions
	b. Business Transactions				f. International Transactions
	c. Payrolls				g. Other (please specify)
	d. WEB Based Transactions
12. If the credit union performs wire transfers, where does the credit union wire funds (check all that apply):
	a. Domestically
	b. Internationally
13. Which processes can a member use to initiate a wire transfer from the credit union (check all that apply):
	a. Email				d. Telephone
	b. Fax				e. In Person
	c. Internet Banking				f. Other (please specify)
14. Statement of Compliance- Minimum Security Devices and Procedures
	I hereby certify to the best of my knowledge and belief that this credit union has developed and administers a security program that equals or exceeds the standards prescribed by Section 748.0 of the NCUA Rules and Regulations; that such security program has been reduced to writing, approved by this credit union's Board of Directors, and have provided for the installation, maintenance, and operation of security devices, if appropriate, in each of the credit union's offices.
	Name of Person Certifying Compliance:_________________________________________
15. If the credit union has undergone a Data Processing Conversion, please provide the following information:
	a. Date of Conversion
	b. Data Processor Converted to
DISASTER RECOVERY INFORMATION
There have been no changes to my Disaster Recovery information since the last time I completed this form
1. In the event of a disaster, will the credit union communicate							Yes	No
	with members through a website?
2. Please check the resources or services you have available and would be willing to share with other credit unions
	during the time of an emergency if you did not need them. (Check all that apply)
	a. Cash Non-Member Share Drafts				d. Mobile Branch
	b. Generator				e. Office Space
	c. IT Support				f. Staff/Management Services
3. If the credit union completed a disaster recovery test since the last time you reported, please provide the date:

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Sheet 17: Reg-14

REGULATORY INFORMATION
Credit Union Name: _____________________________________								Charter Number: _________
1. Please provide the date of the most recent annual meeting held by the credit union.
2. Please provide the date of the most recent financial statement audit.
3. Indicate in the box the number of the description below that best characterizes the
	last audit performed of the credit union's records.
	1 = Financial statement audit performed by state licensed persons
	2 = Balance sheet audit performed by state licensed persons
	3 = Examinations of internal controls over call reporting performed by state licensed persons
	4 = Supervisory Committee audit performed by state licensed persons
	5 = Supervisory Committee audit performed by other external auditors
	6 = Supervisory Committee audit performed by the supervisory committee or designated staff
4. Please provide the effective date of the most recent Supervisory Committee verification
	of member's accounts
5. Indicate in the box the number of the description below that best characterizes who
	completed the verification of member's accounts
	1 = Supervisory Committee 2= Third Party

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Sheet 18: CUSO-15

CREDIT UNION SERVICE ORGANIZATION (CUSO)
List all CUSOs the credit union uses (regardless of whether the credit union has a financial interest) and all the services provided by the CUSO. If the crdit union has a loan, an investmnet, a "controlling financial interest", the " ability tp exert significant influence, or own a smaller portion of the CUSO, please provide the value of the investment in the CUSO, amount loaned to the CUSO, and the Aggregate Cash Outlay in the CUSO, as applicable. See the instructions for additonal instructions. If the credit union needs additional space, please continue on a copy of this form.
Tax ID	Full/Legal Name of CUSO		City	State	See Note Below * ** ***			Investment in CUSO	Loan to CUSO	Aggregate Cash Outlay
* Is the CUSO wholly owned by the credit union? 1 = Yes, 2 = No
** Indicate in the box the letter(s) which describe the service(s) provided by the CUSO:
	a. Checking and Currency Services			h. Insurance brokerage or agency				o. Travel agency services
	b. Clerical, professional and management services			i. Fixed asset services				p. Trust and trust-related services
	c. Shared credit union branch operations			j. Loan support services				q. Real estate brokerage services
	d. Consumer mortgage origination			k. Leasing				r. CUSO investments in non-CUSO service providers
	e. Electronic transaction services			l. Securities brokerage services				s. Other (please identify)
	f. Financial counseling services			m. Business loan origination
	g. Record retention, security & disaster recovery			n. Student loan origination
*** How is the investment in the CUSO accounted for on the credit union's financial statements?
	1 = Consolidation 2 = equity method 3 = cost method

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Sheet 19: Program_Svs-16

CREDIT UNION PROGRAMS AND MEMBER SERVICES
Credit Union Name: _____________________________________								Charter Number: _________
Credit Union Programs - Place an "x" in the box next to all the programs the credit union offers (Check all that apply)
	a. Mortgage Processing					e. Investment Pilot Program
	b. Approved Mortage Seller					f. Investments not authorized by the FCU
	c. Borrowing Repurchase Agreements					Act (State Credit Union Only)
	d. Brokered Deposits (all deposits					g. Deposits and Shares Meeting 703.10(a)
	acquired through a third party)					h. Brokered Certificates of Deposit
Member Service and Product Offerings - Place an "x" in the box next to all the products offered (Check all that apply)
	Transactional					Credit
	a. ATM/Debit Card Program					a. Business Loans
	b. Check Cashing					b. Credit Builder
	c. International Remittances					c. Debt Cancellation/Suspension
	d. Low-cost wire transfers					d. Direct Financing Leases
	e. Money orders					e. Indirect Business Loans
	f. No surcharge ATMs					f. Indirect Consumer Loans
						g. Indirect Mortgage Loans
	Depository					h. Interest Only or Pymt Option 1st
	a. Business Share Accounts					Mortgage Loans
	b. Health Savings Accounts					i. Micro Business Loans
	c. Individual Development Accounts					j. Micro Consumer Loans
	d. No Cost Share Drafts					k. Overdraft Lines of Credit
	e. Share Certificates with low minimum					l. Overdraft Protection/ Courtesy Pay
	balance requirements					m. Participation Loans
						n. Pay Day Loans
	Other Member Services					o. Real Estate Loans
	a. Bilingual Services					p. Refund Anticipation Loans
	b. Insurance/Investment Sales					q. Risk Based Loans
	c. No Cost Bill Payer					r. Share Secured Credit Cards
	d. No Cost Tax Preparation Services
	e. Student Scholarship
	Financial Education
	a. Financial Eductions
	b. Financial Counseling
	c. Financial Literacy Workshops
	d. First Time Homebuyer Program
	e. In School Branches

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Sheet 20: Grants-17

GRANTS AND PARTNERSHIPS
Credit Union Name: _____________________________________							Charter Number: _________
This page is optional for credit unions and not required to be completed. This information will not be released to the public.
Grant Information - Please provide information on any grants you have received since the last time you reported.
	Grantor						Date Awarded	Amount
	NCUA Technical Assistance Program
	Community Development Financial Institutions Fund
	Department of Health and Human Services
	National Credit Union Foundation
	New York State Credit Union Foundation
	Massachusetts Credit Union League
	CUNA
	Association of Credit Union Leagues
	US Department of Labor
	National Federation of Community Development Credit Unions
	US General Services Administration
	US Department of Agriculture
	Enterprise Grant Program
	Other (please specify):
	Other (please specify):
	Other (please specify):
Partnership Information - Please provide information on any partnerships you have with other credit unions.
	Name of Credit Union Partner						Service Type (**)	Relationship Type (***)
	Service Types (**):
	a. ALM			i. Development of New Services			q. Operational resources
	b. Auditing			j. Disaster Recovery			r. Shared branching
	c. Back Office Operations			k. Financial Education			s. Shared employees
	d. Backup Operating Site			l. Grant writing			t. Share operating systems
	e. BSA Training			m. Loan Collections			u. Website assistance
	f. Compliance Review			n. Loan processing/underwriting			v. Other (please specify)
	g. Computer Training			o. Marketing
	h. Data Processing			p. Mentoring
	Relationship Types (***)
	a. Catastrophic Act				f. Seller/Buyer of loan participations
	b. Disaster Recovery				g. Low or no-cost non-member deposits provider
	c. Formal Relationship (under contract)				h. Mentor/mentee
	d. Informal Relationship				i. Other (please specify)
	e. Free Services