1606 Applicant Certification

OMB No. 1550-0047

APPLICANT CERTIFICATION
PAPERWORK REDUCTION ACT STATEMENT
The Office of Thrift Supervision will use this information to evaluate the application against relevant
statutory criteria. Collection is mandatory. Public reporting burden for this collection of information is
estimated to average twenty minutes per response, including the time for reviewing instructions and
completing and reviewing the collection of information. If a valid OMB Control Number does not
appear on this form, you are not required to complete this form. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to the Office of Thrift Supervision, Policy, 1700 G Street, N.W., Washington, D.C.
20552; and to the Office of Management and Budget, Paperwork Reduction Project (1550-0047),
Washington, D.C. 20503.

Please refer to RB 20a and the instructions to this certification prior to completing.
Name of Applicant:

Name of Individual or Entity Submitting Form:

(herein referred to as “you”)
Time Period Covered by Certification:

Submitted in Connection with Application Filed For:

Yes
1. Have you, or any company in which you are, or were, an officer, director, or
principal shareholder, or any partnership in which you are, or were, a partner,
been the subject of any criminal, civil or administrative judgments, consents,
undertakings or orders, or any past or ongoing indictments, investigations,
examinations, or administrative proceedings, issued by any federal or state court,
any department, agency, or commission of the U.S. Government, any state or
municipality, any self regulatory trade or professional organization, or any foreign
government or governmental entity, which involve:

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OTS Form 1606
Revised June 1, 2001

No

OMB No. 1550-0047

Yes
A. Commission of a felony, fraud, moral turpitude, dishonesty, breach of trust or
fiduciary duty, organized crime or racketeering?
B. Violation of securities or commodities laws or regulations?
C. Violation of insurance laws or regulations which involve fraud or a penalty of
$50,000 (per violation) or more?
D. Violation of depository institution laws or regulations?
E. Violation of housing authority laws or regulations?
F. Violation of the rules, regulations, codes of conduct or ethics of a selfregulatory trade or professional organization?
G. Adjudication of bankruptcy or insolvency or appointment of a receiver,
conservator, trustee, referee, or guardian?

2. If you are an insurance company, has any state insurance department suspended
or revoked, or initiated any action to suspend or evoke, your Certificate of
Authority to do business?
3. Have you, or any company in which you are, or were, an officer, director, or
principal shareholder, or any partnership in which you are, or were, a partner,
ever been denied, or withdrawn after receipt of formal or informal notice of a
recommendation for denial, any of the following:
A. An application relating to the organization of, or obtaining insurance of
accounts for, a bank, savings bank, or savings and loan association, trust
company, credit union or industrial bank?
B. An application to acquire any of the foregoing under the Savings and Loan
Holding Company Act or the Bank Holding Company Act?
C. A notice relating to a change in control of any of the foregoing under the
Change in Savings and Loan Control Act or the Change in Bank Control
Act?
D. An application to acquire a foreign bank or parent thereof?

4. Have you been associated as a senior executive officer, director, partner in a
partnership or principal shareholder, with any of the following:
A. An insured depository institution or financial institution holding company that
has been subject to any enforcement action?

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OTS Form 1606
Revised June 1, 2001

No

OMB No. 1550-0047

Yes

No

B. An insured depository institution that: (1) failed, (2) received financial
assistance from a financial institution depository agency (e.g. FDIC,
Resolution Trust Corporation, or former Federal Savings and Loan Insurance
Corporation), or (3) was a merger partner with an institution that received
financial assistance from a financial institution depository agency?
C. A business or enterprise which has filed for bankruptcy or forfeited
property?

5. Do you own any equity securities of an insured institution or holding company
thereof, other than the institution or company that is the subject of the
application?
6. Are/were you a defendant in any pending or settled class action lawsuit that
alleges, or alleged, fraud, dishonesty, misrepresentation, or breach of trust or
fiduciary duty?

Please check one or more of the following. If the form is submitted on behalf of other parties, provide
an attachment that identifies all parties in which it applies.
As Individual - I am executing this form in my individual capacity because I am a controlling
person, senior executive officer or director of the Applicant.
As Applicant - I am executing this form on behalf of the Applicant. Individual forms are
being provided for all companies the Applicant controls, and all of the Applicant’s subsidiaries.
As Applicant - I am executing this form jointly on behalf of the Applicant, all of the companies
it controls, and all affiliates, which are listed as an attachment to the form.

In general, requests for confidential treatment of this form, or any information submitted in response to
this form, must be submitted in writing with its submission and must discuss the justification for the
requested treatment. The Applicant’s reasons for requesting confidentiality should specifically
demonstrate the harm (e.g., to its competitive position, invasion of privacy) that would result from
public release of information (5 U.S.C. Section 552 and 12 C.F.R. Section 505). Information for which
confidential treatment is requested should be separately bound and labeled “Confidential.” The
Applicant should follow the same procedure regarding a request for confidential treatment with regard
to the subsequent filing of supplemental information to the form.

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OTS Form 1606
Revised June 1, 2001

OMB No. 1550-0047

I hereby certify that the information contained in this certification is true, complete, and correct to the
best of my knowledge and belief. I acknowledge that any misrepresentation or omission of a material
fact with respect to the foregoing constitutes fraud in the inducement, or making false statements in
violation of 12 C.F.R. Section 563.180(b), may subject me to legal sanctions provided by 18 U.S.C.
Sections 1001 and 1007.

Signed this _______________ day of _______________
Name of Company, if applicable (print or type name)

Name and Title (print or type)

Signature

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OTS Form 1606
Revised June 1, 2001