3170-XXXX Certification for Entity-Specific Projects (Academic Res

OMB#3170-XXXX
1700 G Street NW, Washington, DC 20552

CERTIFICATION FOR ENTITY-SPECIFIC PROJECTS
Academic Research Council
Project Name: (to be filled in by CFPB)
Brief Project Description: (to be filled in by CFPB)
Specific Entities Involved: (to be filled in by CPPB)
Certification
I certify that I do not have any financial interest in
be filled in by CFPB]

[relevant entity name(s), to

or other financial interests that could influence my work

or advice on this project. If this changes, I will notify the CFPB before continuing
to work on the project.
______________________________________________
Signature

______________________
Date

______________________________________________
Name (Print)

I am unable to certify to the above.
______________________________________________
Signature

______________________
Date

______________________________________________
Name (Print)
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this collection is 3170-00XX. It expires on
XX/XX/XXXX. The time required to complete this information collection is estimated to average
approximately five minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information.