Form FMS 3144 FMS 3144 Minority Bank Deposit Program - Certification for Admiss

OMB No. 1510-0048

MINORITY BANK DEPOSIT PROGRAM

Financial Institution

Certification Form for Admission

I am applying for participation in the Minority Bank Deposit Program (MBDP) administered by the U.S. Department of the Treasury, Financial Management Service.

1. Institution Name _____________________________________________________________________

Address ____________________________________________________________________________

City and State Zip Code___________________________________________ Zip Code ____________

2. Telephone No. Fax No. E-mail __________________________________________________________

3. Routing and Transit Number (ABA #) ____________________________________________________

4. Eligibility: Participation in the Minority Bank Deposit Program requires certification of eligibility by

completing the shares of ownership for each of the following categories:

a) Minority-Owned Bank or Savings and Loans: Yes No

If yes, please complete the number of shares below

H

ispanic or Latino Ethnicity

Black or African American

American Indian or Alaska Native Native Hawaiian or Other Pacific Islander

Asian

White

2. Women-Owned Bank or Savings and Loans: Yes No

If yes, please complete the number of shares below

H

ispanic or Latino Ethnicity

Black or African American

American Indian or Alaska Native Native Hawaiian or Other Pacific Islander

Asian

White

c) Low-Income Credit Union designated by the National Credit Union Administration: Yes No

5. Total Shares: _______________ Total Minority Shares: __________

6. Percentage of Minority Ownership: _____________

(If applying under the control criteria, in addition to completing items 1 through 6, attach copies of executed voting trust and/or proxy agreements. These agreements must have a life of at least three years, be irrevocable, and the trustee (a member of a minority group) must have unfettered discretion in voting the stock.)

I hereby certify that each member of a minority or women's group is either a U.S. citizen or a U.S. resident.

I agree that, after acceptance into the MBDP, the institution shall immediately notify the Financial Management Service (FMS) of any change in ownership and/or control that could affect program eligibility.

I agree that if the institution provides erroneous information or fails to notify FMS of any changes in ownership and/or control which render the institution ineligible to participate in the MBDP, the institution shall lose all rights to benefits that are being received as a result of its status as a MBDP participant, and if the institution receives funds, including but not limited to the Treasury Tax & Loan non-interest bearing deposit from FMS, it shall return such funds to FMS and shall reimburse FMS for the imputed value of the funds at the Federal funds rate less 25 basis points from the time that the institution becomes ineligible for the MBDP until such funds are received by FMS.

I hereby certify that all of the above information is true and accurate, and I understand that any misrepresentation of fact is subject to the criminal code provisions of Title 18, Section 1001 of the United States Code.

Signature ___________________________

Affix Bank or Notary Print Name __________________________

Public seal

Title________________________________

Not valid without seal

Date _______________________________

U.S. Department of the Treasury

Financial Management Service

Bank Policy and Oversight Division

401 14^th Street, S.W., Room 317

Washington, DC 20227

DEPARTMENT OF THE TREASURY

FINANCIAL MANAGEMENT SERVICE

FMS FORM 3144 EDITION OF 12-99

Minority Bank Deposit Program

Eligibility Requirements

The eligibility requirements for participation in the Minority Bank Deposit Program (MBDP) are as follows:

1. Each member of a minority or women’s group having control or ownership of the institution is either a U.S. citizen or a U.S. resident.

2. Minority Banks and Stock Saving and Loans:

(a) Ownership: More than 50 percent of the outstanding stock must be owned by members of a minority groups; or

(b) Control: A financial institution must be able to demonstrate that minorities hold, by means of voting trust and/or proxy agreements, enough shares so that when added to the shares owned by minorities, minorities control over 50 percent of the outstanding stock for voting purposes.

3. Women Banks: More than 50 percent of the outstanding stock must be owned by women, a majority of the Board of Directors must be women, and a significant percentage of senior management positions must be held by women.

4. Mutual Savings and Loans: A majority of the board of Directors must be members of minority groups.

5. Women Stock Savings and Loans: More than 50 percent of the outstanding stock must be owned by women, a majority of the Board of Directors must be women, and a significant percentage of senior management positions must be held by women.

6. Women Mutual Savings and Loans: A majority of the Board of Directors must be women and a significant percentage of senior management positions must be held by women.

7. Low-income Credit Unions: All financial institutions must be designated low-income by the National Credit Union Administration (NCUA).

If a minority or women's certification includes stock held by corporations, partnerships, trusts, etc., the financial institution must certify that each such entity is minority owned or controlled, or in the case of women's institutions owned, controlled, and operated by women.

Paperwork Reduction Act and Privacy Act Statement

The information provided to the Department of the Treasury on this form is used solely to determine the financial institution's eligibility to participate in the Financial Management Service’s Minority Bank Deposit Program. Failure to respond in part or in total to this request will result in the financial institution's exclusion from consideration for, or expulsion from, the Minority Bank Deposit Program.

Burden Estimate Statement

The estimated average burden associated with this collection is 30 minutes per respondent or record keeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestion for reducing this burden should be directed to the Financial Management Service, Facilities Management Division, Property & Supply Section, Room 100, Ardmore East Business Center, 3361- L 75th Avenue, Landover, MD 20785 or the Office of Management and Budget, Paperwork Reduction Project (1510-0048), Washington, DC 20503.