Form Member Director 1 Member Director 1 Federal Home Loan Bank Member Director Eligibility Certi

FEDERAL HOME LOAN BANK
MEMBER 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 2/28/2011
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FEDERAL HOME LOAN BANK MEMBER DIRECTOR ELIGIBILITY CERTIFICATION FORM

6. 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 Member
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 2/28/2011
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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 a
member 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 1261 of Title 12 of the Code of Federal Regulations
(12 C.F.R. part 1261). A copy of the statutory and regulatory eligibility requirements is enclosed
for your reference. Only individuals who satisfy these requirements may run for a member
directorship or serve as a member director.
Nominees for a Member Bank Directorship
If you wish to accept a nomination to serve as a member director, you must complete this Form
. If you do not submit this Form to
and return it to the Bank on or before
the Bank by the deadline, you will be deemed to have declined the nomination.
Incumbent Member Bank Directors
Every year, each incumbent member director must complete this Form and return it to the Bank
on or before March 1st. The Bank will use the information to confirm your continued eligibility
to serve as a member 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 member director, and may declare
vacant the member 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
. You cannot become a member director
and return it to the Bank on or before
unless you complete and return the Form to the Bank.

Expires 2/28/2011
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FEDERAL HOME LOAN BANK MEMBER 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 member 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 a member 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 a member 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 2/28/2011
OMB No. 2590-0006

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