NCUA 4501A NCUA Profile Form and Instructions

Revisions to NCUA Call Reports

December 2012 Profile Form_Final

Revisions to NCUA Call Reports

OMB: 3133-0004

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3133-0004 can be found here:

2023-12-18 - No material or nonsubstantive change to a currently approved collection
2023-06-30 - No material or nonsubstantive change to a currently approved collection

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NATIONAL CREDIT UNION ADMINISTRATION
ALEXANDRIA, VIRGINIA 22314-3428
OFFICIAL BUSINESS

Credit Union Profile Form and Instructions
Fourth Quarter 2012
MUST BE RECEIVED BY: January 18, 2013

TO THE BOARD OF DIRECTORS OF THE CREDIT UNION
ADDRESSED:
This booklet contains the fourth quarter 2012 Profile form and instructions.
All credit unions that filed this completed form in a previous cycle and are
filing manually must complete pages 1, 2, 16, 17, and 18 of this form, as
applicable. Additionally, credit unions must report any changes to their sites,
contacts, and IS&T information previously reported on pages 3 - 15.
This paper form is provided for your convenience; however, only credit unions
with a manual filing status should complete this form and return it to the
contact identified on the enclosed instructional letter.
If you are currently identified as a manual filer and would like to submit your
data electronically, please notify your NCUA Regional Office or your state
credit union supervisor, as appropriate. NCUA's Technical Customer Support
Desk can assist you with obtaining a username and password to access Credit
Union Online.
Please return this booklet as soon as possible, but no later than
January 18, 2013. Please follow the instructions carefully.
If you have any non-technical questions, please contact your National Credit
Union Administration Regional Office or your state credit union supervisor, as
appropriate. Please call NCUA Customer Service at 1-800-827-3255 with any
technical questions.

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REPORTING INSTRUCTIONS
Credit unions that have submitted this completed form in a previous cycle are only required to
complete the areas that have changed since the last time they filed. If you are unsure of the
information in your online profile and do not have Internet access, you can request a copy of
your profile from your NCUA Regional Office or state credit union supervisor, as appropriate.
If there are no changes to a specific area, please check the box titled "No changes".

All credit unions filing this form manually must complete the following pages each call
report cycle and return them to the contact identified on the enclosed instructional letter.
Page 1 - Certification Page - sign the certification page
Page 2 - Certify Compliance with NCUA Rules and Regulations Part 748
Page 16 - Regulatory Page - All sections
Page 17 - CUSO Page - All sections, as applicable
Page 18 - Program and Member Services - All sections, as applicable
Providing Updated Information: In accordance with NCUA Rules and Regulations Part 741,
credit unions are required to update their profile information within 10 days of the election or
appointment of senior management and volunteer officials, or within 30 days of any change.
Online filing credit unions will make these changes in the online system. Manual filing credit
unions will update their information on this paper form and send it to their regulator.
Records Retention: Credit unions should retain a copy of this completed form each cycle as a
part of the permanent records of the credit union.

The instructions to prepare this form meet the requirement to provide guidance to small credit unions under Section
212 of the Small Business Regulatory Enforcement Fairness Act of 1996.
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act
unless the form displays a valid OMB control number.
Public reporting burden of this collection of information is estimated to average 6.6 hours per response, including
the time for reviewing instructions, searching existing data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspects of this collection of information,
including suggestions for reducing this burden to:
National Credit Union Administration
Office of the Chief Information Officer
1775 Duke Street
Alexandria, VA 22314-3428

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CERTIFICATION
Credit Union Name:

__________________________________ Charter Number: _________

I understand each operating insured credit union must update their credit union profile within 10
days after the election or appointment of senior management or volunteer officials, or within 30
days of any change of the information in the profile. I hereby certify to the best of my knowledge
and belief the information provided is current and 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:
Please Print

Full Name:

_________________________ First Name: ________________Date:___________
Certified Correct By

________________________________________________
Certified Correct By (Signature)

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CERTIFY COMPLIANCE MINIMUM SECURITY DEVICES AND PROCEDURES
NCUA RULES AND REGULATIONS PART 748
FEDERALLY INSURED CREDIT UNIONS ONLY
Credit Union Name:

__________________________________ Charter Number: _________

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 Part 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 this credit union has provided for the installation,
maintenance, and operation of security devices, if appropriate, in each of its offices. Further, I
certify that I am the president or managing official of the credit union or that the president or
managing official has authorized me to make this submission on his/her behalf.

Please Print

_________________________ First Name: ________________Date:___________
Certified By

Title:

________________________________

Last Name:

Please Print

Full Name:

________________________________________________
Certified By (Signature)

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GENERAL INFORMATION
Credit Union Name:

__________________________________ Charter Number: _________

There have been no changes to this information since the last time I completed this form.

1. Indicate the type of credit committee the credit union has:
1 = Elected 2 = Appointed 3 = No Committee
2. Select the box next to the credit union's Primary Settlement Agent (i.e., member share draft
clearing, ACH transactions, etc.--See Instructions.)
Federal Reserve Bank
Other Credit Union
CUSO
Bank
Corporate Credit Union
Not Applicable
Federal Credit Union
3. Provide the credit union's Employer Identification Number (EIN):
Yes

4. Is your credit union a member of the Federal Home Loan Bank?
5. Has your credit union filed an application to borrow from the
Federal Reserve Bank Discount Window?
6. Has your credit union pre-pledged collateral with the Federal
Reserve Bank Discount Window?

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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, Patriot Act 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 or CEO

*CU Employment: ___________________________________________

*Salutation:_____*First Name:________________Middle Initial:_____ *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 Initial:_____ *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 Initial:_____ *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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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: Board Secretary *CU Employment: _____________________________________________
*Salutation:_____*First Name:________________Middle Initial:_____ *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: Board Treasurer *CU Employment: ___________________________________________
*Salutation:_____*First Name:________________Middle Initial:_____ *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 Initial:_____ *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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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 Initial:_____ *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 Initial:_____ *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 Initial:_____ *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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CONTACTS (4)
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 Credit Committee Members, please continue on a copy of this form.
J. *Job Title: Credit Committee Chairperson

*CU Employment: ____________________

*CU Employment: ______________________

*CU Employment: _____________________

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CONTACTS (5)
Credit Union Name:

__________________________________Charter Number: _________

There have been no changes to my contacts since the last time I completed this form.
This page is required for Federal Credit Unions.
If the credit union has additional Supervisory Committee Members, please continue on a copy of this form.
M. *Job Title: Supervisory Committee Chairperson *CU Employment:_________________
*Salutation:_____*First Name:________________Middle Initial:_____ *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 Initial:_____ *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 Initial:_____ *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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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 Initial:_____ *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 Initial:_____ *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 Initial:_____ *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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CONTACTS (7) MANDATORY ROLES
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 mandatory roles. 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 Initial:____ *Last Name:__________________
Work Email:________________________________Home Email:______________________________
*Work Phone: ________________________ Extension:___________
B. *Role: Profile Information Contact *Job Title: ______________*CU Employment:____________________
*Salutation:______*First Name:_________________Middle Initial:____ *Last Name:__________________
Work Email:________________________________Home Email:______________________________
*Work Phone: ________________________ Extension:___________
C. *Role: Primary Patriot Act Contact *Job Title: ______________*CU Employment:___________________
*Salutation:______*First Name:_________________Middle Initial:____ *Last Name:__________________
*Work Email:________________________________ *Fax Number:____________________________
*Work Phone: ________________________ Extension:___________
D. *Role: Secondary Patriot Act Contact *Job Title: ______________*CU Employment:_________________
*Salutation:______*First Name:_________________Middle Initial:____ *Last Name:__________________
*Work Email:________________________________ *Fax Number:____________________________
*Work Phone: ________________________ Extension:___________
E. *Role: Primary Emergency Contact *Job Title: ________________*CU Employment:__________________
*Salutation:______*First Name:_________________Middle Initial:____ *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 Initial:____ *Last Name:__________________
*Work or Home Email:_______________________________ Cell Phone:___________________________
*Work or Home Phone (please identify): ________________________ Extension:___________

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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.
*Site Type: Corporate Office *Site Name: _________________ *Site Function(s):__________________
__________ ____________________________
*Is Main Office: Yes *Hours of Operation: _________________ *Operational Status: __________________
*Phone:____________________ Extension:________ Fax:_____________________

Is Foreign: ________

*Physical Address: _______________________________________________ *Country:_______________
*Physical City:______________________________ *State:________*Zip Code: ___________
*Mailing Address: ___________________________________________ *Country:__________________
*Mailing 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:_____________________

Is Foreign: ________

*Physical Address: ______________________________________________ *Country:_______________
*Physical City:______________________________ *State:________ *Zip Code: ___________
Mailing Address: ___________________________________________ Country:__________________
Mailing 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:_____________________

Is Foreign: ________

*Physical Address: ______________________________________________* Country:_______________
*Physical City:______________________________ *State:________ *Zip Code: ___________
Mailing Address: ___________________________________________ Country:__________________
Mailing City:_______________________________ State:________ Zip Code: ____________
D. Identify the site where the credit union maintains its records.
*Site Type: ______________________ *Site Name: _____________*Site Function(s): Location of Records
*Is Main Office: ___ Hours of Operation: ________________ *Operational Status: __________________
*Phone:____________________ Extension:________ Fax:_____________________

Is Foreign: ________

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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, including Shared Branch/Networks, the credit union may have.
Mandatory fields are identified with an asterisk (*). Please reference the instructions for additional guidance.
Additional branch locations can be recorded on page 11 or on a copy of this form.
E. Identify Shared Service Center/Networks site for the credit union, if applicable.
*Site Type:_____________*Site Name: _________________

*Site Function: Shared Service Center/Network

*Is Main Office: No *Hours of Operation: _________________ *Operational Status: __________________
*Phone:____________________ Extension:________ Fax:_____________________

Is Foreign: ________

*Site Function(s):__________________

*Is Main Office: No *Hours of Operation: _________________ *Operational Status: __________________
*Phone:____________________ Extension:________ Fax:_____________________

Is Foreign: ________

*Site Function(s):__________________

*Is Main Office: No *Hours of Operation: _________________ *Operational Status: __________________
*Phone:____________________ Extension:________ Fax:_____________________

Is Foreign: ________

*Site Function(s):__________________

*Is Main Office: No *Hours of Operation: _________________ *Operational Status: __________________
*Phone:____________________ Extension:________ Fax:_____________________

Is Foreign: ________

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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 the credit union's hot site, if applicable, all other locations where the credit union maintains its
records, or any vacant land, future office locations, planned evacuation 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 hot site for the credit union, if applicable.
*Site Type: _______________ *Site Name: _________________

*Site Function: Hot Site

*Is Main Office: No *Hours of Operation: ________________ *Operational Status: ________________
*Phone:____________________ Extension:________ Fax:_____________________

Is Foreign: ________

*Site Function(s):__________________

*Is Main Office: No *Hours of Operation: ________________ *Operational Status: ________________
*Phone:____________________ Extension:________ Fax:_____________________

Is Foreign: ________

*Site Function(s):__________________

*Is Main Office: No *Hours of Operation: _________________ *Operational Status: __________________
*Phone:____________________ Extension:________ Fax:_____________________

Is Foreign: ________

*Site Function(s):__________________

*Is Main Office: No *Hours of Operation: _________________ *Operational Status: __________________
*Phone:____________________ Extension:________ Fax:_____________________

Is Foreign: ________

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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

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 identify the type of website
1 = Informational 2 = Interactive 3 = Transactional
b. If the credit union plans to add a transactional website, please provide the name of the primary vendor
to deliver such services
c. Please provide an implementation date
3. If the credit union has an organizational email address, please provide it.
Yes

Yes

4. Does the credit union have Internet access?
5. Does the credit union have an internal wireless network?
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/loan data 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. Account Aggregation
k. Member Application
b. Account Balance Inquiry
l. Merchandise Purchase
c. Bill Payment
m. Merchant Processing Services
d. Download Account History
n. New Loan
e. Electronic Cash
o. New Share Account
f. Electronic Signature
p. Remote Deposit Capture
Authentication/Certification
q. Share Account Transfers
g. e-Statements
r. Share Draft Orders
h. External Account Transfers
s. View Account History
i. Internet Access Services
j. Loan Payments
Other (please specify)

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IS&T (2), PAYMENT SYSTEM SERVICE PROVIDER, 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.
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)
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.
b.
c.
d.

Consumer Transactions
Business Transactions
Payrolls
WEB Based Transactions

e. TEL Based Transactions
f. International Transactions
g. Other (please specify)

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
b. Fax
c. Internet Banking

d. Telephone
e. In Person
f. Other (please specify)

PAYMENT SYSTEM SERVICE PROVIDER INFORMATION
1. Does your credit union use a corporate credit union for payment system services? If no, stop here. If yes,
please complete the following chart for all corporate credit union relationships. See instructions.
a. Name of Corporate CU

b. Payment Services Used (see instructions for list)

2. Are you planning to change this payment system provider relationship within the next 12 months and/or have
you started to transition to a new provider? If no, stop here. If yes, please complete the following for all
changes. If you need more space, continue on a copy of this form. See instructions.
a. Provider You Plan to or Have
Changed to

b. Payment Service(s) Affected

c.
Percentage
of
Transition
Complete

d.
Transition
of any
service
100%
complete?

e. Payment Service(s)
100% Complete

DATA PROCESSING CONVERSION
If the credit union has undergone or plans to undergo a Data Processing Conversion, please provide the following:
a. Date of Conversion
b. Data Processor Converting/Converted to

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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 members' accounts
5. Indicate in the box the number of the description below that best characterizes who
completed the verification of members' accounts
1 = Supervisory Committee
2= Third Party
6. Indicate the Fidelity Bond Provider
7. Indicate the amount of Fidelity Coverage for any Single Loss (RR 713.5)
8. If you have 100 or more employees or 50 or more employees with a Federal contract of at least $50,000, what is the last
date you filed an EEO-1 Survey Report with the Equal Employment Opportunity Commission?

(MM/DD/YYYY)
9. Do you have a diversity policy or program in your credit union? (Yes/No)
10. I hereby certify to the best of my knowledge and belief that this credit union is in compliance with Section 701.4 of the
NCUA Rules and Regulations, and the board has established policies to make available the appropriate training to enhance the
financial knowledge of directors, commensurate with the size and complexity of the credit union.
Certifier First Name
Certifier Last Name
Certifier Title

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 with members through

Yes

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. Please provide the date of the last disaster recovery test completed by the credit union.

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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 credit union has a loan, an investment, a
"controlling financial interest", the ability to exert significant influence, or owns 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 additional guidance. If the credit union needs additional space, please continue on a copy of this
form.
CUSO EIN

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.
b.
c.
d.
e.
f.
g.

Checking and currency services
Clerical, professional and management services
Business loan origination
Consumer mortgage origination
Electronic transaction services
Financial counseling services
Fixed asset services

h. Insurance brokerage or agency
i. Leasing
j. Loan support services
k. Record retention, security, and disaster recovery services
l. Securities brokerage services
m. Shared credit union branch (service center) operations
n. Student loan origination

o. Travel agency services
p. Trust and trust-related services
q. Real estate brokerage services
r. CUSO investments in non-CUSO service providers
s. Credit card loan origination
t. Payroll processing services
u. Other (please identify)

*** How is the investment in the CUSO accounted for on the credit union's financial statements?
1 = Consolidation

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2 = equity method

3 = cost method

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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.
b.
c.
d.

Mortgage Processing
Approved Mortgage Seller
Borrowing Repurchase Agreements
Brokered Deposits (all deposits
acquired through a third party)
e. Investment Pilot Program

f. Investments not authorized by the FCU
Act (State Credit Union Only)
g. Deposits and Shares Meeting 703.10(a)
h. Brokered Certificates of Deposit
i. Short-Term, Small Amount Loans (FCU Only)

Member Service and Product Offerings - Place an "x" in the box next to all the products offered (Check all that apply)

Transactional

Financial Education

a.
b.
c.
d.
e.
f.

a.
b.
c.
d.
e.

ATM/Debit Card Program
Check Cashing
International Remittances
Low-cost wire transfers
Money orders
No surcharge ATMs

Financial Counseling
Financial Education
Financial Literacy Workshops
First Time Homebuyer Program
In-School Branches

Credit
Depository
a.
b.
c.
d.
e.

Business Share Accounts
Health Savings Accounts
Individual Development Accounts
No Cost Share Drafts
Share Certificates with low minimum
balance requirements

Other Member Services
a.
b.
c.
d.
e.

Bilingual Services
Insurance/Investment Sales
No Cost Bill Payer
No Cost Tax Preparation Services
Student Scholarship

a.
b.
c.
d.
e.
f.
g.
h.

Business Loans
Credit Builder
Debt Cancellation/Suspension
Direct Financing Leases
Indirect Business Loans
Indirect Consumer Loans
Indirect Mortgage Loans
Interest Only or Payment Option 1st
Mortgage Loans
i. Micro Business Loans
j. Micro Consumer Loans
k. Overdraft Lines of Credit
l. Overdraft Protection/ Courtesy Pay
m. Participation Loans
n. Payday Loans
o. Real Estate Loans
p. Refund Anticipation Loans
q. Risk Based Loans
r. Share Secured Credit Cards

Short Term, Small Amount Loan Program (Federal Credit Unions Only):
If the credit union offers Short-Term, Small Amount Loans, does your program include any of the following: (check all that apply)
a. Credit Bureau Reporting
b. Financial Education
c. Forced Savings Component
d. Payroll Deduction
Minority Credit Union Questions:
1. Does your credit union have more than 50% of its current members and management officials who are Black American,
Native American, Hispanic American, or Asian American? If yes, please identify the minority group(s) that apply:
Black American

Hispanic American

Native American

Asian American

2. Does your credit union have more than 50% of its eligible potential members and management officials who are Black American,
Native American, Hispanic American, or Asian American? If yes, please identify the minority group(s) that apply:
Black American

Hispanic American

Native American

Asian American

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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
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):

Date Awarded

Amount

Partnership Information - Please provide information on any partnerships you have with other credit unions.
Name of Credit Union Partner

Service Types (**):
a. Asset Liability Management
b. Auditing
c. Back Office Operations
d. Backup Operating Site
e. Bank Secrecy Act Training
f. Compliance Review
g. Computer Training
h. Data Processing

i. Development of New Services
j. Disaster Recovery
k. Financial Education
l. Grant writing
m. Loan Collections
n. Loan processing/underwriting
o. Marketing
p. Mentoring

Relationship Types (***)
a. Catastrophic Act
b. Disaster Recovery
c. Formal Relationship (under contract)
d. Informal Relationship
e. Free Services

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Service Type Relationship
(**)
Type (***)

f.
g.
h.
i.

q. Operational resources
r. Shared branching
s. Shared employees
t. Shared operating systems
u. Website assistance
v. Other (please specify)
______________________

Seller/Buyer of loan participations
Low or no-cost non-member deposits provider
Mentor/mentee
Other (please specify)

__________________________

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MERGER PARTNER REGISTRY
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.
Yes

1. Is your credit union interested in expanding its field of
membership through a consolidation of another credit union?
If yes, please proceed to the remaining questions.
2. Please provide the name and phone number of the person at the credit union who can be contacted
regarding any potential consolidations.
*Title________________*First Name:__________________________*Last Name:____________________________
*Phone: _______________________ *Extension: __________

3. Please identify the geographic areas in which the credit union would be interested. (Check only ONE
Box)
Anywhere in the U.S.
Anywhere within the selected states (Please specify states)

Specific counties/cities within a selected state (Specify the state on lines above)

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File Type	application/pdf
Author	AMBER GRAVIUS
File Modified	2012-11-29
File Created	2012-11-29