Form Elective Director Elective Director FEDERAL HOME LOAN BANK ELECTIVE DIRECTOR ELIGIBILITY CER

FEDERAL HOME LOAN BANK ELECTIVE
DIRECTOR ELIGIBILITY CERTIFICATION FORM
1. Print or type your full name:
________________________________________________________________________

2. Are you a citizen of the United States? Yes ____ No ____

3. Provide the address of your principal residence:
_____________________________________
Street

______________________ _____________
City
State

________
Zip code

4. Provide the following information about the institution you serve as an officer or director that
is a member of your Federal Home Loan Bank:

____________________________________________
Name of member

_______________________________________
Your title or position

_______________________ ___________________________ _________________________________
Telephone number
Fax number
E-mail address

_____________________________________ _______________________
Street
City

_____________ ________
State
Zip code

_____________________________________ _______________________ ______________ ________
Mailing address (if different)
City
State
Zip code

5. Provide the name and location of any other institution you serve as an officer or a director that
is a member of any Federal Home Loan Bank:
__________________________
Name of member

______________________ __________ _____________________
City
State
Your title or position

__________________________
Name of member

______________________ __________ _____________________
City
State
Your title or position

Expires 11/30/2007
OMB No. 3069-0002

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FEDERAL HOME LOAN BANK ELECTIVE DIRECTOR ELIGIBILITY CERTIFICATION FORM
-16. Does each member listed in LINE 4 and LINE 5 comply with all of its applicable minimum
capital requirements established by its appropriate federal or state regulator?
Yes ____

No ____

I HEREBY CERTIFY that the information provided on this Federal Home Loan Bank Elective
Director Eligibility Certification Form is true, correct, and complete to the best of my
knowledge.

________________________________________________
Signature

_________________________
Date

State of _______________ )
County of _____________ )
Signed and sworn to before me this ____ day of __________________ of 20___.

___________________________________
Signature of Notary Public

(Notarial Seal)
My commission expires: _____________________

Expires 11/30/2007
OMB No. 3069-0002

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DIRECTIONS
If you need assistance in completing this Form or have any questions, please contact:
Name:
Federal Home Loan Bank of
Address:
Telephone:
Fax:
E-Mail:

Who Must File and When
The Federal Home Loan Bank (Bank) uses the information you provide on this Form to
determine whether you meet the statutory and regulatory eligibility requirements to serve as an
elective Bank director. You can find these requirements in section 1427 of Title 12 of the United
States Code (12 U.S.C. § 1427) and in part 915 of the Title 12 of the Code of Federal
Regulations (12 C.F.R. part 915). A copy of the statutory and regulatory eligibility requirements
is enclosed for your reference. Only individuals who satisfy these requirements may run for an
elective directorship or serve as an elective director.
Nominees for an Elective Bank Directorship
If you wish to accept a nomination to serve as an elective Bank director, you must complete this
Form and return it to the Bank on or before [Insert Date]. If you do not submit this Form to the
Bank by the deadline, you will be deemed to have declined the nomination.
Incumbent Elective Bank Directors
Every year, each incumbent elective director must complete this Form and return it to the Bank
on or before March 1st. The Bank will use information to confirm your continued eligibility to
serve as an elective director. If you do not submit this form by the March 1st deadline, the Bank
may declare that you are no longer eligible to serve as a Bank director, and may declare vacant
the elective directorship that you hold. If March 1st falls on a Saturday, Sunday, or federal
holiday, you have until the next business day to submit the completed Form.
Individuals Selected to Fill a Vacancy
If the Bank selected you to fill a vacancy on the board of directors, you must complete this Form
and return it to the Bank on or before [Insert Date]. You cannot become an elective director
unless you complete and return the Form to the Bank.

Expires 11/30/2007
OMB No. 3069-0002

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FEDERAL HOME LOAN BANK ELECTIVE DIRECTOR ELIGIBILITY CERTIFICATION FORM: DIRECTIONS

Line-by-Line Instructions
LINE 1. Print or type your full name.

LINE 2. You must be a United States citizen in order to serve as a Bank director. Check the
appropriate answer.

LINE 3. Provide the address of your principal residence.

LINE 4. You must be an officer or a director of an institution that is a member of the Bank in
order to be an elective director of that Bank. In addition, the member must be located in the state
within the Bank district that is to be represented by the directorship you wish to hold. In most
cases, a member will be deemed to be located where it maintains its home office or its principal
place of business. Provide the requested information for the member you serve as an officer or
director, as well as your title or position at that institution.

LINE 5. If you are an officer or director of any other institution that is a member of this or any
other Bank, provide the name and location of the institution(s), as well as the position that you
hold at the institution(s).

LINE 6. In order for you to be eligible to serve as an elective Bank director, every Bank
member you serve as an officer or director must be in compliance with all of its applicable
minimum capital requirements established by its appropriate federal or state regulator. The term
“appropriate federal regulator” has the same meaning as the term “appropriate Federal banking
agency” in section 3(q) of the Federal Deposit Insurance Act (12 U.S.C. § 1813(q)), and, for
federally insured credit unions, means the National Credit Union Administration. The term
“appropriate state regulator” means any State officer, agency, supervisor, or other entity that has
regulatory authority over, or is empowered to institute enforcement action against, a member.
Each institution you listed in LINE 4 and LINE 5 must be in compliance with all of the
applicable minimum capital requirements established by its appropriate federal or state regulator.
Please check the appropriate answer to this question.

Expires 11/30/2007
OMB No. 3069-0002

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