NCUA 4501A NCUA Profile Form and Instructions

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Overview

Cover
Instruct
Certification
Certify Compliance
General Info
Contacts
Contacts (2)
Contacts (3)
Contacts (4)
Contacts (5)
Contacts (6)
Contacts (7)
Sites
Sites (2)
Sites (3)
IS&T_DP Conversion
PaymentSystemServiceProvider
Regulatory&DisasterRecovery
CUSO
CU Programs_Mem Svs
Grants
Partnerships
Merger Partner Registry

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Sheet 1: Cover

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Sheet 2: Instruct

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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Sheet 3: Certification

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).
Certified By
Last Name :				First Name :					Date :
Please Print		Certified Correct By
Full Name :
		Certified Correct By (Signature)

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Sheet 4: Certify Compliance

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.
Certified By
Last Name :				First Name :					Date :
Please Print		Certified By
Job Title :
Please Print
Full Name :
		Certified By (Signature)

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Sheet 5: General Info

GENERAL INFORMATION

Credit Union Name :

Charter Number :

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

1 . Select the type of credit committee the credit union has :

a. Elected

b. Appointed

c. No Committee

2 . Select the credit union's Primary Settlement Agent (i.e., Member share draft clearing, ACH transactions, etc. -- See Instructions)

a. Federal Reserve Bank

b. CUSO

c. Corporate Credit Union

d. Federal Credit Union

e. Other Credit Union

f. Bank

g. Not Applicable

3 . Provide the credit union's Employer Identification Number (EIN) :

4 . Is your credit union a member of the Federal Home Loan Bank?

a. Yes

b. No

5 . Has your credit union filed an application to borrow from the Federal Reserve Bank Discount Window?

a. Yes

b. No

6 . Has your credit union pre-pledged collateral with the Federal Reserve Bank Discount Window?

a. Yes

b. No

7 . Provide the Research Statistics Supervision and Discount (RSSD) Number issued by the Board of Governors of the Federal Reserve System :

7 . Assets of the Credit Union :

8 . Number of Members of the Credit Union :

9 . Peer Group of the Credit Union :

10 . Credit Union Website Address :

11 . NCUA Examiner Contact Name :

12 . NCUA Examiner Contact Email Address :

13 . NCUA Supervisory Examiner Contact Name :

14 . NCUA Supervisory Examiner Email Address :

15 . Provide the Profile Certifier Name :

16 . Provide the Profile Certifification Date :

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Sheet 6: Contacts

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.
		Home Address				Work Address
A. *Job Title :	Manager or CEO	*Line 1 :				Line 1 :
*Salutation :		Line 2 :				Line 2 :
*First Name :		*City :				City :
Middle Name :		County :				County :
*Last Name :		*State :		*Zip :		State :		Zip :
*Employment Type :		*Country :				Country :
*Role(s) :		*Phone :				Phone :		Ext. :
		Fax :		Cell :		Fax :		Cell :
		Email :				Email :
B. *Job Title :	Chairperson	*Line 1 :				Line 1 :
*Salutation :		Line 2 :				Line 2 :
*First Name :		*City :				City :
Middle Name :		County :				County :
*Last Name :		*State :		*Zip :		State :		Zip :
*Employment Type :		*Country :				Country :
*Role(s) :		*Phone :				Phone :		Ext. :
		Fax :		Cell :		Fax :		Cell :
		Email :				Email :
C. *Job Title :	Vice Chairperson	*Line 1 :				Line 1 :
*Salutation :		Line 2 :				Line 2 :
*First Name :		*City :				City :
Middle Name :		County :				County :
*Last Name :		*State :		*Zip :		State :		Zip :
*Employment Type :		*Country :				Country :
*Role(s) :		*Phone :				Phone :		Ext. :
		Fax :		Cell :		Fax :		Cell :
		Email :				Email :

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Sheet 7: Contacts (2)

CONTACTS (2)
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.
		Home Address				Work Address
D. *Job Title :	Board Secretary	*Line 1 :				Line 1 :
*Salutation :		Line 2 :				Line 2 :
*First Name :		*City :				City :
Middle Name :		County :				County :
*Last Name :		*State :		*Zip :		State :		Zip :
*Employment Type :		*Country :				Country :
*Role(s) :		*Phone :				Phone :		Ext. :
		Fax :		Cell :		Fax :		Cell :
		Email :				Email :
E. *Job Title :	Board Treasurer	*Line 1 :				Line 1 :
*Salutation :		Line 2 :				Line 2 :
*First Name :		*City :				City :
Middle Name :		County :				County :
*Last Name :		*State :		*Zip :		State :		Zip :
*Employment Type :		*Country :				Country :
*Role(s) :		*Phone :				Phone :		Ext. :
		Fax :		Cell :		Fax :		Cell :
		Email :				Email :
F. *Job Title :	Board Member	*Line 1 :				Line 1 :
*Salutation :		Line 2 :				Line 2 :
*First Name :		*City :				City :
Middle Name :		County :				County :
*Last Name :		*State :		*Zip :		State :		Zip :
*Employment Type :		*Country :				Country :
*Role(s) :		*Phone :				Phone :		Ext. :
		Fax :		Cell :		Fax :		Cell :
		Email :				Email :

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Sheet 8: Contacts (3)

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.
		Home Address				Work Address
G. *Job Title :	Board Member	*Line 1 :				Line 1 :
*Salutation :		Line 2 :				Line 2 :
*First Name :		*City :				City :
Middle Name :		County :				County :
*Last Name :		*State :		*Zip :		State :		Zip :
*Employment Type :		*Country :				Country :
*Role(s) :		*Phone :				Phone :		Ext. :
		Fax :		Cell :		Fax :		Cell :
		Email :				Email :
H. *Job Title :	Board Member	*Line 1 :				Line 1 :
*Salutation :		Line 2 :				Line 2 :
*First Name :		*City :				City :
Middle Name :		County :				County :
*Last Name :		*State :		*Zip :		State :		Zip :
*Employment Type :		*Country :				Country :
*Role(s) :		*Phone :				Phone :		Ext. :
		Fax :		Cell :		Fax :		Cell :
		Email :				Email :
I. *Job Title :	Board Member	*Line 1 :				Line 1 :
*Salutation :		Line 2 :				Line 2 :
*First Name :		*City :				City :
Middle Name :		County :				County :
*Last Name :		*State :		*Zip :		State :		Zip :
*Employment Type :		*Country :				Country :
*Role(s) :		*Phone :				Phone :		Ext. :
		Fax :		Cell :		Fax :		Cell :
		Email :				Email :

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Sheet 9: Contacts (4)

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.
		Home Address				Work Address
J. *Job Title :	Credit Committee Chairperson	*Line 1 :				Line 1 :
*Salutation :		Line 2 :				Line 2 :
*First Name :		*City :				City :
Middle Name :		County :				County :
*Last Name :		*State :		*Zip :		State :		Zip :
*Employment Type :		*Country :				Country :
*Role(s) :		*Phone :				Phone :		Ext. :
		Fax :		Cell :		Fax :		Cell :
		Email :				Email :
K. *Job Title :	Credit Committee Member	*Line 1 :				Line 1 :
*Salutation :		Line 2 :				Line 2 :
*First Name :		*City :				City :
Middle Name :		County :				County :
*Last Name :		*State :		*Zip :		State :		Zip :
*Employment Type :		*Country :				Country :
*Role(s) :		*Phone :				Phone :		Ext. :
		Fax :		Cell :		Fax :		Cell :
		Email :				Email :
L. *Job Title :	Credit Committee Member	*Line 1 :				Line 1 :
*Salutation :		Line 2 :				Line 2 :
*First Name :		*City :				City :
Middle Name :		County :				County :
*Last Name :		*State :		*Zip :		State :		Zip :
*Employment Type :		*Country :				Country :
*Role(s) :		*Phone :				Phone :		Ext. :
		Fax :		Cell :		Fax :		Cell :
		Email :				Email :

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Sheet 10: Contacts (5)

	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.
			Home Address				Work Address
	M. *Job Title :	Supervisory Committee Chairperson	*Line 1 :				Line 1 :
	*Salutation :		Line 2 :				Line 2 :
	*First Name :		*City :				City :
	Middle Name :		County :				County :
	*Last Name :		*State :		*Zip :		State :		Zip :
	*Employment Type :		*Country :				Country :
	*Role(s) :		*Phone :				Phone :		Ext. :
			Fax :		Cell :		Fax :		Cell :
			Email :				Email :
	N. *Job Title :	Supervisory Committee Member	*Line 1 :				Line 1 :
	*Salutation :		Line 2 :				Line 2 :
	*First Name :		*City :				City :
	Middle Name :		County :				County :
	*Last Name :		*State :		*Zip :		State :		Zip :
	*Employment Type :		*Country :				Country :
	*Role(s) :		*Phone :				Phone :		Ext. :
			Fax :		Cell :		Fax :		Cell :
			Email :				Email :
	O. *Job Title :	Supervisory Committee Member	*Line 1 :				Line 1 :
	*Salutation :		Line 2 :				Line 2 :
	*First Name :		*City :				City :
	Middle Name :		County :				County :
	*Last Name :		*State :		*Zip :		State :		Zip :
	*Employment Type :		*Country :				Country :
	*Role(s) :		*Phone :				Phone :		Ext. :
			Fax :		Cell :		Fax :		Cell :
			Email :				Email :

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Sheet 11: Contacts (6)

	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.
			Home Address				Work Address
	P. *Job Title :		*Line 1 :				Line 1 :
	*Salutation :		Line 2 :				Line 2 :
	*First Name :		*City :				City :
	Middle Name :		County :				County :
	*Last Name :		*State :		*Zip :		State :		Zip :
	*Employment Type :		*Country :				Country :
	*Role(s) :		*Phone :				Phone :		Ext. :
			Fax :		Cell :		Fax :		Cell :
			Email :				Email :
	Q. *Job Title :		*Line 1 :				Line 1 :
	*Salutation :		Line 2 :				Line 2 :
	*First Name :		*City :				City :
	Middle Name :		County :				County :
	*Last Name :		*State :		*Zip :		State :		Zip :
	*Employment Type :		*Country :				Country :
	*Role(s) :		*Phone :				Phone :		Ext. :
			Fax :		Cell :		Fax :		Cell :
			Email :				Email :
	R. *Job Title :		*Line 1 :				Line 1 :
	*Salutation :		Line 2 :				Line 2 :
	*First Name :		*City :				City :
	Middle Name :		County :				County :
	*Last Name :		*State :		*Zip :		State :		Zip :
	*Employment Type :		*Country :				Country :
	*Role(s) :		*Phone :				Phone :		Ext. :
			Fax :		Cell :		Fax :		Cell :
			Email :				Email :

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Sheet 12: Contacts (7)

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

*Salutation :

Work Email :

*Job Title :

*First Name :

Home Email :

Middle Name :

*Work Phone :

*Employment Type :

*Last Name :

Extension :

B. *Role :

Profile Information Contact

*Salutation :

Work Email :

*Job Title :

*First Name :

Home Email :

Middle Name :

*Work Phone :

*Employment Type :

*Last Name :

Extension :

C. *Role :

Primary Patriot Act Contact

*Salutation :

Work Email :

*Job Title :

*First Name :

Home Email :

Middle Name :

*Work Phone :

*Employment Type :

*Last Name :

Extension :

D. *Role :

Secondary Patriot Act Contact

*Salutation :

Work Email :

*Job Title :

*First Name :

Home Email :

Middle Name :

*Work Phone :

*Employment Type :

*Last Name :

Extension :

E. *Role :

Primary Emergency Contact

*Salutation :

Work Email :

*Job Title :

*First Name :

Home Email :

Middle Name :

*Work Phone :

*Employment Type :

*Last Name :

Extension :

F. *Role :

Secondary Emergency Contact

*Salutation :

Work Email :

*Job Title :

*First Name :

Home Email :

Middle Name :

*Work Phone :

*Employment Type :

*Last Name :

Extension :

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Sheet 13: Sites

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.

Physical Address

Mailing Address

*Site Type :

Corporate Office

*Line 1 :

*Line 1 :

*Site Name :

Line 2 :

Line 2 :

*Operational Status :

*City :

*City :

*Is Main Office :

Yes

Fax :

County :

County :

*Phone Number :

Ext. :

*State :

*Zip :

*State :

*Zip :

*Hours of Operation :

*Country :

*Country :

*Site Function(s) :

B. Identify the Disaster Recovery Location information in this section.

*Site Type :

*Line 1 :

*Line 1 :

*Site Name :

Line 2 :

Line 2 :

*Operational Status :

*City :

*City :

*Is Main Office :

No

Fax :

County :

County :

*Phone Number :

Ext. :

*State :

*Zip :

*State :

*Zip :

*Hours of Operation :

*Country :

*Country :

*Site Function(s) :

Disaster Recovery Location

C. Identify the Vital Records Center information in this section. (Required by Rules and Regs Part 749)

*Site Type :

*Line 1 :

*Line 1 :

*Site Name :

Line 2 :

Line 2 :

*Operational Status :

*City :

*City :

*Is Main Office :

No

Fax :

County :

County :

*Phone Number :

Ext. :

*State :

*Zip :

*State :

*Zip :

*Hours of Operation :

*Country :

*Country :

*Site Function(s) :

Vital Records Center

D. Identify the site where the credit union maintains its records.

*Site Type :

*Line 1 :

*Line 1 :

*Site Name :

Line 2 :

Line 2 :

*Operational Status :

*City :

*City :

*Is Main Office :

Fax :

County :

County :

*Phone Number :

Ext. :

*State :

*Zip :

*State :

*Zip :

*Hours of Operation :

*Country :

*Country :

*Site Function(s) :

Location of Records

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Sheet 14: Sites (2)

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 a copy of this form.

E. Identify Shared Service Center/Networks site for the credit union, if applicable.

Physical Address

Mailing Address

*Site Type :

*Line 1 :

*Line 1 :

*Site Name :

Line 2 :

Line 2 :

*Operational Status :

*City :

*City :

*Is Main Office :

No

Fax :

County :

County :

*Phone Number :

Ext. :

*State :

*Zip :

*State :

*Zip :

*Hours of Operation :

*Country :

*Country :

*Site Function(s) :

Shared Service Center/Network

F. Identify Branch location information in this section.

*Site Type :

Branch Office

*Line 1 :

*Line 1 :

*Site Name :

Line 2 :

Line 2 :

*Operational Status :

*City :

*City :

*Is Main Office :

No

Fax :

County :

County :

*Phone Number :

Ext. :

*State :

*Zip :

*State :

*Zip :

*Hours of Operation :

*Country :

*Country :

*Site Function(s) :

G. Identify Branch location information in this section.

*Site Type :

Branch Office

*Line 1 :

*Line 1 :

*Site Name :

Line 2 :

Line 2 :

*Operational Status :

*City :

*City :

*Is Main Office :

No

Fax :

County :

County :

*Phone Number :

Ext. :

*State :

*Zip :

*State :

*Zip :

*Hours of Operation :

*Country :

*Country :

*Site Function(s) :

H. Identify Branch location information in this section.

*Site Type :

Branch Office

*Line 1 :

*Line 1 :

*Site Name :

Line 2 :

Line 2 :

*Operational Status :

*City :

*City :

*Is Main Office :

No

Fax :

County :

County :

*Phone Number :

Ext. :

*State :

*Zip :

*State :

*Zip :

*Hours of Operation :

*Country :

*Country :

*Site Function(s) :

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Sheet 15: Sites (3)

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. Additional branch locations can be recorded on a copy of this form.

I. Identify the hot site for the credit union, if applicable.

Physical Address

Mailing Address

*Site Type :

*Line 1 :

*Line 1 :

*Site Name :

Line 2 :

Line 2 :

*Operational Status :

*City :

*City :

*Is Main Office :

No

Fax :

County :

County :

*Phone Number :

Ext. :

*State :

*Zip :

*State :

*Zip :

*Hours of Operation :

*Country :

*Country :

*Site Function(s) :

Hot Site

J. Credit unions may identify any additional sites they have in this section. See instructions.

*Site Type :

*Line 1 :

*Line 1 :

*Site Name :

Line 2 :

Line 2 :

*Operational Status :

*City :

*City :

*Is Main Office :

No

Fax :

County :

County :

*Phone Number :

Ext. :

*State :

*Zip :

*State :

*Zip :

*Hours of Operation :

*Country :

*Country :

*Site Function(s) :

K. Credit unions may identify any additional sites they have in this section. See instructions.

*Site Type :

*Line 1 :

*Line 1 :

*Site Name :

Line 2 :

Line 2 :

*Operational Status :

*City :

*City :

*Is Main Office :

No

Fax :

County :

County :

*Phone Number :

Ext. :

*State :

*Zip :

*State :

*Zip :

*Hours of Operation :

*Country :

*Country :

*Site Function(s) :

L. Credit unions may identify any additional sites they have in this section. See instructions.

*Site Type :

*Line 1 :

*Line 1 :

*Site Name :

Line 2 :

Line 2 :

*Operational Status :

*City :

*City :

*Is Main Office :

No

Fax :

County :

County :

*Phone Number :

Ext. :

*State :

*Zip :

*State :

*Zip :

*Hours of Operation :

*Country :

*Country :

*Site Function(s) :

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Sheet 16: IS&T_DP Conversion

INFORMATION SYSTEMS AND TECHNOLOGY (IS&T)

Credit Union Name :

Charter Number :

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

1. Does the credit union have a website?

a. Yes

b. No

a. Website Address :

b. Is website hosted internally ?

a. Yes

b. No

c. Select only one type of website :

a. Informational

b. Interactive

b. Transactional

d. Transactional website Vendor :

2. If the credit union does not have a website and plans to add one in the future,

a. Select type of website :

a. Informational

b. Interactive

b. Transactional

b. Transactional website Vendor for Planned Website :

c. Implementation Date :

3. Organizational email address :

4. Does the credit union have Internet access?

a. Yes

b. No

5. Does the credit union have an internal wireless network?

a. Yes

b. No

6. Data Processing System used to maintain CU records :

a. Manual System

b. Vendor Supplied In-House System

c. Vendor On-line Service Bureau

d. CU Developed In-house System

e. Other

7. Name of the primary share/loan data processing vendor :

8. How members access/perform electronic financial services

a. Home Banking via Internet Website

c. Automatic Teller Machine (ATM)

e. Kiosk

b. Audio Response/Phone Based

d. Mobile Banking

f. Other

9. Services offered electronically

a. Account Aggregation

f. Electronic Signature Auth./Cert.

k. Member Application

p. Remote Deposit Capture

b. Account Balance Inquiry

g. e-Statements

l. Merchandise Purchase

q. Share Account Transfers

c. Bill Payment

h. External Account Transfers

m. Merchant Processing Svs

r. Share Draft Orders

d. Download Account History

i. Internet Access Services

n. New Loan

s. View Account History

e. Electronic Cash

j. Loan Payments

o. New Share Account

t. Mobile Payments

t. Other (Please Specify)

10. Systems used to process electronic payments

a. Fedline Advantage

b. Corporate Credit Union

c. Correspondent Bank

d. CUSO

e. CHIPS

f. FedGlobal ACH

g. EPN

h. Other (Please Specify)

11. If the credit union performs ACH transfers, where does the credit union transfer funds (check all that apply):

a. Domestically

b. Internationally

12. If the credit union is an Originating Depository Financial Institution, ACH transactions originated by the credit union

a. Consumer Transactions

c. Payrolls

e. TEL Based Transactions

b. Business Transactions

d. WEB Based Transactions

f. International Transactions

g. Other (Please Specify)

13. If the credit union performs wire transfers, where the credit union wire funds

a. Domestically

b. Internationally

14. Processes a member can use to initiate a wire transfer from the credit union (check all that apply):

a. Email

c. Internet Banking

e. In Person

b. Fax

d. Telephone

f. Other (Please Specify)

DATA PROCESSING CONVERSIONS

Date of Conversion :

Data Processor Converting/Converted To :

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Sheet 17: PaymentSystemServiceProvider

PAYMENT SYSTEM SERVICE PROVIDER INFORMATION (PSSP)

Credit Union Name :

Charter Number :

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

1. Does your credit union use a corporate credit union for payment system services? (Yes/No)

a. Name of Corporate CU :

b. Payment Services Used :

2. Are you planning to change this payment system relationship within the next 12 months and/or have you started to transition to a new provider? (Yes/No)

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 ? (Yes/No)

e. Payment Service(s) 100% Complete :

1. Does your credit union use a corporate credit union for payment system services? (Yes/No)

a. Name of Corporate CU :

b. Payment Services Used :

2. Are you planning to change this payment system relationship within the next 12 months and/or have you started to transition to a new provider? (Yes/No)

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 ? (Yes/No)

e. Payment Service(s) 100% Complete :

1. Does your credit union use a corporate credit union for payment system services? (Yes/No)

a. Name of Corporate CU :

b. Payment Services Used :

2. Are you planning to change this payment system relationship within the next 12 months and/or have you started to transition to a new provider? (Yes/No)

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 ? (Yes/No)

e. Payment Service(s) 100% Complete :

1. Does your credit union use a corporate credit union for payment system services? (Yes/No)

a. Name of Corporate CU :

b. Payment Services Used :

2. Are you planning to change this payment system relationship within the next 12 months and/or have you started to transition to a new provider? (Yes/No)

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 ? (Yes/No)

e. Payment Service(s) 100% Complete :

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Sheet 18: Regulatory&DisasterRecovery

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. Please select the last type of audit performed for the credit union's records :

a. Financial statement audit performedby state licensed persons

b. Balance sheet audit performed by state licensed persons

c. Examinations of internal controls over call reporting performed by state licensed persons

d. Supervisory Committee audit performed by state licensed persons

e. Supervisory Committee audit performed by other external auditors

f. Supervisory Committee audit performed by the supervisory committee or designated staff

4. Provide the name of the Financial Statement Audit Firm or Auditor :

5. Please provide the effective date of the most recent Supervisory Committee verification of member's accounts :

6. Please select who completed the verification of member's accounts :

a. Supervisory Committee

b. Third Party

7. Provide the date of the most recent Bank Secrecy Act Independent Test :

8. Provide you Supervisory Committee contact information for official correspondence :

Mailing Address :

Email:

Mailing City

State :

Zip Code :

9. Indicate the Fidelity Bond Provider Name :

10. Indicate the amount of Fidelity Coverage for any Single Loss (RR 713.5) :

11. Please provide the Part 701.4 Certification Date :

12. Please provide the Part 701.4 Certifier Name :

13. Does your credit union meet any of the following criteria? If yes, answer the following:

A. What is the last date you filed an EEO-1 Survery Report with the U.S.Equal Employment Opportunity Commission ? (MM/DD/YYYY)

B. Do you have a diversity policy and/or program in your credit union?

Yes

No

- Credit union with 100 or more employees; or

- Credit union with 50 or more employees and:

1. Has a contract of at least $50,000 with the Federal government; or

2. Serves as a depository of U.S. government funds of any amount; or

3. Serves as a paying agent for U.S. Savings Bonds.

14. Provide any trade names the credit union uses for signage or advertising.

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 a website ?

a. Yes

b. No

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

c. IT Support

e. Office Space

b. Generator

d. Mobile Branch

f. Staff/Management Services

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

3. Indicate the method(s) used for the last disaster recovery test completed by the credit union.

a. Orientation/Walk Through

b. Tabletop/Mini-drill

c. Functional Testing

d. Full-Scale Testing

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Sheet 19: CUSO

CREDIT UNION SERVICE ORGANIZATION (CUSO)
Credit Union Name :								Charter Number :
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 :		Wholly Owned :
Invest Accounted For :		Investment in CUSO :			Loan to CUSO :			Aggregate Cash Outlay :
Services :
CUSO EIN :		Full/Legal Name of CUSO :				City :		State :		Wholly Owned :
Invest Accounted For :		Investment in CUSO :			Loan to CUSO :			Aggregate Cash Outlay :
Services :
CUSO EIN :		Full/Legal Name of CUSO :				City :		State :		Wholly Owned :
Invest Accounted For :		Investment in CUSO :			Loan to CUSO :			Aggregate Cash Outlay :
Services :
CUSO EIN :		Full/Legal Name of CUSO :				City :		State :		Wholly Owned :
Invest Accounted For :		Investment in CUSO :			Loan to CUSO :			Aggregate Cash Outlay :
Services :
CUSO EIN :		Full/Legal Name of CUSO :				City :		State :		Wholly Owned :
Invest Accounted For :		Investment in CUSO :			Loan to CUSO :			Aggregate Cash Outlay :
Services :
CUSO EIN :		Full/Legal Name of CUSO :				City :		State :		Wholly Owned :
Invest Accounted For :		Investment in CUSO :			Loan to CUSO :			Aggregate Cash Outlay :
Services :
CUSO EIN :		Full/Legal Name of CUSO :				City :		State :		Wholly Owned :
Invest Accounted For :		Investment in CUSO :			Loan to CUSO :			Aggregate Cash Outlay :
Services :
CUSO EIN :		Full/Legal Name of CUSO :				City :		State :		Wholly Owned :
Invest Accounted For :		Investment in CUSO :			Loan to CUSO :			Aggregate Cash Outlay :
Services :
CUSO EIN :		Full/Legal Name of CUSO :				City :		State :		Wholly Owned :
Invest Accounted For :		Investment in CUSO :			Loan to CUSO :			Aggregate Cash Outlay :
Services :

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Sheet 20: CU Programs_Mem Svs

CREDIT UNION PROGRAMS AND MEMBER SERVICES
Credit Union Name :								Charter Number :
Credit Union Programs - Place a "ü" in the associated box to all the credit union offers (Check all that apply)
	a. Mortgage Processing					f. Investments not authorized by the FCU Act (State CU Only)
	b. Approved Mortgage Seller					g. Deposits and Shares Meeting 703.10(a)
	c. Borrowing Repurchase Agreements					h. Brokered Certificates of Deposit
	d. Brokered Deposits (all deposits acquired through a third party)					i. Short-Term, Small Amount Loans (FCU Only)
	e. Investment Pilot Program
Member Service and Product Offerings - Place a "ü" in the associated box to all the credit union offers (Check all that apply)
	Transactional					Credit
	a. ATM/Debit Card Program					a. Business Loans
	b. Check Cashing					b. Credit Builder
	c. Prepaid Debit Cards					c. Debt Cancellation/Suspension
	d. Low-cost wire transfers					d. Direct Financing Leases
	e. Money orders					e. Indirect Business Loans
	f. No surcharge ATMs					f. Indirect Consumer Loans
	Depository					g. Indirect Mortgage Loans
	a. Business Share Accounts					h. Interest Only or Pymt Option 1st Mortgage Loans
	b. Health Savings Accounts					i. Micro Business Loans
	c. Individual Development Accounts					j. Micro Consumer Loans
	d. No Cost Share Drafts					k. Overdraft Lines of Credit
	e. Share Certificates with low minimum balance requirement					l. Overdraft Protection/ Courtesy Pay
	Other Member Services					m. Participation Loans
	a. Bilingual Services					n. Pay Day Loans
	b. Insurance/Investment Sales					o. Real Estate Loans
	c. No Cost Bill Payer					p. Refund Anticipation Loans
	d. No Cost Tax Preparation Services					q. Risk Based Loans
	e. Student Scholarship					r. Share Secured Credit Cards
	Financial Education					Remittance Transfers
	a. Financial Counseling					a. International Remittances
	b. Financial Education					b. Low Cost Wire Transfers
	c. Financial Literacy Workshops					c. Proprietary remittance transfer services operated by the CU
	d. First Time Homebuyer Program					d. Proprietary remittance transfer servics operated by another person
	e. In-School Branches
Short Term, Small Amount Loan Program (FCUs Only) - Place a "ü" in the associated box to all the credit union offers (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 eligible potential or current members who are Black or African
American, Native American, Hispanic American, or Asian American? (Yes/No)
If Yes, identify the minority group(s) that apply :
	Black or African American					Hispanic American
	Native American					Asian American
2. Does your credit union have more than 50% of its current management officials who are Black or African American
Native American, Hispanic American, or Asian American? (Yes/No)
If Yes, identify the minority group(s) that apply :
	Black or African American					Hispanic American
	Native American					Asian American

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Sheet 21: Grants

CREDIT UNION GRANTS INFORMATION
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 (See Instructions)							Grant Type *	Date Awarded		Amount
	Government (State, Local, Federal)
	Trade Associations
	Credit Unions and Banks
	Foundations (local and national)
	* Grant Types		a. Capital - unrestricted donation of equity			c. Program Grant
			b. Subsidy for Risk or ALLL			d. Pass Through

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Sheet 22: Partnerships

CREDIT UNION PARTNERSHIPS INFORMATION
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.
Partnership Information - Please provide information on any partnerships you have with other credit unions.
	Name of Credit Union Partner			Service Type (**)			Relationship Type (***)

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Sheet 23: Merger Partner Registry

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.
1. Is your credit union interested in expanding its Field Of Membership through a consolidation of another credit union?
				a. Yes			b. No
		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.
		*Job Title :
		*First Name :						*Last Name :
		*Phone :						*Extension :
3. Please identify the geographic areas in which the credit union would be interested. (Select only ONE Box)
		Anywhere in the United States
		Anywhere within Selected States (Please specify states)
		Specific Counties/Cities within a Selected State (Specify the state on lines above)
		State			County/Counties				City/Cities