Form 3170-XXXX Application to Serve as a Small Entity Representative

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

APPLICATION TO SERVE AS A SMALL ENTITY REPRESENTATIVE
Consumer Financial Protection Bureau
The Consumer Financial Protection Bureau (“CFPB”) may obtain input from small businesses
and other entities that are likely to be directly affected by a regulation that the CFPB may issue.
Under the law, when a rule under development may have a significant economic impact on a
substantial number of small entities, representatives from the CFPB, the Chief Counsel for
Advocacy of the Small Business Administration, and the Office of Management and Budget’s
Office of Information and Regulatory Affairs form a Small Business Review Panel (“SBREFA
Panel or “Panel”). The Panel then meets with a selected group of representatives from small
businesses and other entities.
During the Panel outreach meeting, the CFPB reviews the regulatory proposals and options or
alternatives under consideration with the participating small entity representatives. The
representatives then discuss and provide the Panel with important feedback on the potential costs
and other economic impacts of complying with the proposed regulations under consideration and
any potential regulatory alternatives to minimize these impacts while accomplishing the
objectives of applicable statutes. During the Panel outreach meeting or a separate consultation
meeting with small entities, the CFPB may also solicit feedback on how the proposals under
consideration may impact the cost of credit for small entities and ways to minimize any such
impact. Small entity representatives will also have an opportunity to provide feedback through
the submission of written comments.
The CFPB is looking for individual representatives of small businesses and other organizations
who are interested in meeting with the Panel or participating in other CFPB outreach meetings
and providing feedback on the potential economic impacts of proposed regulations under
consideration. This form will allow the CFPB to compile a list of potential representatives of
small businesses and other organizations.
If you or your institution is interested in participating, please provide us with your contact
information and information on the institution you represent. Some respondents may then be
contacted and asked to participate in a Panel outreach meeting or other CFPB outreach event.
ABOUT YOU:
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Name
Title
E-Mail
Phone

ABOUT YOUR BUSINESS OR ORGANIZATION:
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Name
Address
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Application to Serve as a Small Entity Representative, Consumer Financial Protection Bureau

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

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City, State, Zip Code
Type (you may choose more than one) [drop-down or list with boxes to be checked]
o Commercial Bank
o Credit Union
o Savings Bank/Savings Institution
o Mortgage Lender
o Mortgage Brokerage
o Mortgage Servicer
o Other Brokerage
o Payday Lender
o Private Education Lender
o Student Loan Servicer
o Automobile Finance Company
o Other Consumer Finance Company
o Credit Reporting Agency
o Debt Collector
o Money Transmitter
o Check Casher
o Other Money Services Business
o Debt Relief/Settlement Company
o Prepaid Value Issuer or Program Manager
o Nonbank Credit Card Issuer
o Payment Processor
o Payment Network
o Non-Profit Entity
o Governmental Entity
o Other (please specify)

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Total Assets (for depository institutions) (determine by averaging the assets (defined
according to the Federal Financial Institutions Examination Council 034 call report form)
reported on the institution’s four quarterly financial statements for the preceding year)

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Total Revenue (for non-depository institutions) (determine by averaging the revenues or
receipts reported on IRS tax return forms over last three fiscal years; include revenue of
any affiliates in this calculation)

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Number of Employees

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Scope and Nature of Business Activities (e.g., types of products or services offered)

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Names and Description of Affiliated Entities (entities are affiliates of each other when
one controls or has the power to control the other, or a third party or parties controls or
has the power to control both)
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Application to Serve as a Small Entity Representative, Consumer Financial Protection Bureau

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

-

Memberships or Affiliations with Trade Associations or Other Organizations

Thank you for providing this information.
Privacy Act Notice
The information that you provide will be used by the Consumer Financial Protection Bureau
(CFPB) to determine qualifications, suitability and availability for service on/to advisory boards,
bodies, panels, committees or groups or as a small entity representative to provide feedback to a
Small Business Review Panel (SBREFA panel). The contact and background information is
shared with the Small Business Administration (SBA). The information/advice we collect for
SBREFA panels may be shared with other agencies, specifically SBA and the Office of
Management and Budget, who are SBREFA panel members. The information collected will be
for annual reports on advisory boards, bodies, panels, committees or other similar groups. The
information will be used by and disclosed to employees, contractors, agents, and others
authorized by the CFPB to receive this information to assist in related activities. Additionally,
the names and biographies of panel members will be released to the public.
The information may also be disclosed to:





the office of the President or a member of Congress;
to a court, a party in litigation, a magistrate, an adjudicative body or
administrative tribunal in the course of a proceeding, or the Department of
Justice; and
to other federal or state agencies or regulatory authorities for enforcement and
statutory purposes.

The collection of this information is authorized by Pub. L. No. 111-203, Title X, sections 1011,
1012, 1014, codified at 12 U.S.C. §§ 5491, 5492, 5494.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
collection is 3170-XXXX.It expires on MM/DD/YYYY. The time required to complete this information collection is estimated
to average approximately 10 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information.
The Consumer Financial Protection Bureau (CFPB) prohibits discrimination in all its programs and activities on the basis of race,
color, national origin, gender, religion, age, political beliefs, sexual orientation, marital or family status, parental status or
protected genetic information. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative
means of communication of program information (Braille, large print, audiotape, etc.) should contact Liza Strong, Labor and
Employee Relations, Office of Human Capital. To file a complaint of discrimination, contact the Treasury Department at 202622-9252. CFPB is an equal opportunity provider and employer.

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Application to Serve as a Small Entity Representative, Consumer Financial Protection Bureau