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pdfNATIONAL CREDIT UNION ADMINISTRATION
ALEXANDRIA, VIRGINIA 22314-3428
OFFICIAL BUSINESS
Credit Union Profile Form and Instructions
TO THE BOARD OF DIRECTORS OF THE CREDIT UNION ADDRESSED:
This booklet contains the Form 4501A Profile. The effective date of this form is
September 30, 2016 and will remain in effect until superseded. Instructions and
quarterly filing dates for completing the form are available on the NCUA’s
website at www.ncua.gov.
The Profile Reporting Instructions page contains the filing requirements. Please
note, the Profile must be certified in conjunction with the filing of the Form 5300
Call Report.
The NCUA website provides the quarterly filing date. In addition, credit union
contacts of record will continue to receive quarterly email notifications of the
cycle highlights.
If you have any questions, please contact your National Credit Union
Administration Regional Office or your state credit union supervisor, as
appropriate. Please direct any technical questions to NCUA Customer Service at
1-800-827-3255.
OMB No. 3133-0004
NCUA Profile Form 4501A
Effective March 31, 2017
Previous Editions Are Obsolete
REPORTING REQUIREMENTS
Provide Updated Information: In accordance with NCUA Rules and Regulations Part
741, insured 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.
Records Retention: Credit unions should retain a copy of the information used to
complete the profile 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 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
OMB No. 3133-0004
NCUA Profile Form 4501A
Effective March 31, 2017
Previous Editions Are Obsolete
Report Date: ______________
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 :
Please Print
First Name :
Date :
Certified Correct By
Full Name :
Certified Correct By (Signature)
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NCUA Profile Form 4501A
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Page 1
Report Date: ______________
CERTIFY COMPLIANCE MINIMUM SECURITY DEVICES AND PROCEDURES
NCUA RULES AND REGULATIONS PART 748
FEDERALLY INSURED CREDIT UNIONS ONLY
Charter Number :
Credit Union Name :
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 :
Please Print
First Name :
Date :
Certified By
Job Title :
Please Print
Full Name :
Certified By (Signature)
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Previous Editions Are Obsolete
Page 2
Report Date: ______________
GENERAL INFORMATION
Charter Number :
Credit Union Name :
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
e. Other Credit Union
f. Bank
g. Not Applicable
d. Federal Credit Union
3 . Provide the credit union's Employer Identification Number (EIN) :
4. Provide the Research Statistics Supervision and Discount (RSSD) ID number issued
by the Board of Governors of the Federal Reserve System.
5 . Is your credit union a member of the Federal Home Loan Bank?
a. Yes
b. No
6 . Has your credit union filed an application to borrow from the Federal Reserve Bank Discount Window?
a. Yes
b. No
7 . Has your credit union pre-pledged collateral with the Federal Reserve Bank Discount Window?
a. Yes
OMB No. 3133-0004
b. No
NCUA Profile Form 4501A
Effective March 31, 2017
Previous Editions Are Obsolete
Page 3
Report Date: ______________
INFORMATION SYSTEMS AND TECHNOLOGY (IS&T)
Charter Number :
Credit Union Name :
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
b. Is website hosted internally ?
a. Yes
b. No
c. Select only one type of website :
a. Informational
b. Interactive
a. Website Address :
c. 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 :
1. Informational
2. Interactive
3. Transactional
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
b. Transactional website Vendor for Planned Website :
c. Implementation Date :
3. Organizational email address :
6. Data Processing System used to maintain CU records :
a. Manual System
b. Vendor Supplied In-House System
d. CU Developed In-house System
e. Other
c. Vendor On-line Service Bureau
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
f. Electronic Signature Auth./Cert.
k. Member Application
9. Services offered electronically
a. Account Aggregation
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
d. CUSO
u. Other (Please Specify)
10. Systems used to process electronic payments (check all that apply)
a. Fedline Advantage
b. Corporate Credit Union
c. Correspondent Bank
e. CHIPS
f. FedWire
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 does the credit union wire funds (check all that apply):
a. Domestically
b. Internationally
14. Which processes can a member use to initiate electronic payments (e.g. wire transfer, ACH, etc.) from the credit union (check all that apply):
a. Email
c. Internet Banking
b. Fax
d. Telephone
e. In Person
f. Other (Please Specify)
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NCUA Profile Form 4501A
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Page 4
Report Date: ______________
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 :
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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Page 5
Report Date: ______________
REGULATORY INFORMATION
Charter Number :
Credit Union Name :
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 performed by 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 Audit Firm or Auditor (see instructions)
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 your Supervisory Committee contact information for public/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 Section 701.4 certification date (Federal Credit Unions Only):
Certification Date
12. Please provide Section 701.4 certifier's name (Federal Credit Unions Only):
Certified By
13. Please provide Section 701.4 certifier's job title (Federal Credit Unions Only):
Job Title
14. Does your credit union meet any of the following criteria? (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.
14a. If yes, what is the last date you filed an EEO-1 Survey Report with the U.S.
Equal Employment Opportunity Commission (MM/DD/YYYY)?
14b. If yes, do you have a diversity policy and/or program in your credit union? (Yes/No)
15. List any trade names the credit union uses for signage or advertising.
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NCUA Profile Form 4501A
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Page 6
Report Date: ______________
DISASTER RECOVERY INFORMATION
Charter Number :
Credit Union Name :
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
3. Please provide the date of the last disaster recovery test completed by the credit union :
a. Indicate the method(s) used for the last disaster recovery test completed by the credit union.
1. Orientation/Walk Through
3. Functional Testing
2. Tabletop/Mini-Drill
4. Full-Scale Testing
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NCUA Profile Form 4501A
Effective March 31, 2017
Previous Editions Are Obsolete
Page 7
Report Date: ______________
CREDIT UNION PROGRAMS AND MEMBER SERVICES
Credit Union Name :
Charter Number :
Credit Union Programs - Place a "" in the associated box for 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. Payday Alternative Loans (PAL loans) (FCU Only)
e. Investment Pilot Program (FCU Only)
Member Service and Product Offerings - Place a "" in the associated box for all the credit union offers (Check all that apply)
Transactional
Financial Education
a. ATM/Debit Card Program
a. Financial Counseling
b. Check Cashing
b. Financial Education
c. Money orders
c. Financial Literacy Workshops
d. No surcharge ATMs
d. First Time Homebuyer Program
e. Prepaid Debit Cards
e. In-School Branches
Depository
Credit
a. Business Share Accounts
a. Business/Commercial Loans
b. Health Savings Accounts
b. Credit Builder
c. Individual Development Accounts
c. Debt Cancellation/Suspension
d. No Cost Share Drafts
d. Direct Financing Leases
e. Share Certificates with low minimum balance requirement
e. Indirect Business/Commercial Loans
Other Member Services
f. Indirect Consumer Loans
a. Bilingual Services
g. Indirect Mortgage Loans
b. Insurance/Investment Sales
h. Interest Only or Pymt Option 1st Mortgage Loans
c. No Cost Bill Payer
i. Micro Business Loans
d. No Cost Tax Preparation Services
j. Micro Consumer Loans
e. Student Scholarship
k. Overdraft Lines of Credit
Consumer Initiated Remittance Transfers
l. Overdraft Protection/ Courtesy Pay
a. International Remittances
m. Participation Loans
b. Low-cost Wire Transfers
n. Pay Day Loans
c. Proprietary remittance transfer services operated by the CU
o. Real Estate Loans
d. Proprietary remittance transfer services operated by another person
p. Refund Anticipation Loans
q. Risk Based Loans
r. Share Secured Credit Cards
Payday Alternative Loans (PAL loans) program (FCUs Only) - Place a "" in the associated box for all the credit union offers (Check all that apply)
a. Credit Bureau Reporting
b. Financial Education
c. Forced Savings Component
d. Payroll Deduction
Minority Depository Institution Questions
1. Are more than 50% of your credit union’s current and eligible potential members 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. Is more than 50% of your credit union’s board of directors 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
OMB No. 3133-0004
NCUA Profile Form 4501A
Effective March 31, 2017
Previous Editions Are Obsolete
Page 8
Report Date: ______________
CREDIT UNION GRANT INFORMATION
Credit Union Name :
Charter Number :
The Grant section of this page must be completed if the credit union receives grant funds.
Grant Information - Please provide information on any grants you have received since the last time you reported.
Grantor Type and Grantor
Date Awarded
Amount
Awarded
Grant Type*
Government (State, Local, Federal)
Community Development Financial Institution
Department of Education
Department of Health and Human Services
Federal Home Loan Bank
Housing and Urban Development
Internal Revenue Service
NCUA Technical Assistance Program
Small Business Administration
US Department of Agriculture
Other (Please Specify):
Other (Please Specify):
Trade Associations
National Credit Union Foundation
National Federation of Community Development Credit Unions
State League Foundation
Other (Please Specify):
Credit Unions and Banks
Specify Name:
Specify Name:
Foundations (local and national)
Specify Name:
Specify Name:
*Grant Types:
a. Capital - unrestricted donation to equity
c. Program Grant
b. Subsidy for Risk or ALLL
d. Pass Through
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NCUA Profile Form 4501A
Effective March 31, 2017
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Page 9
Report Date: ______________
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
OMB No. 3133-0004
Service Type
NCUA Profile Form 4501A
Effective March 31, 2017
Previous Editions Are Obsolete
Relationship Type
Page 10
Report Date: ______________
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. Mandatory fields are
identified with an asterisk (*).
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
OMB No. 3133-0004
County/Counties
NCUA Profile Form 4501A
Effective March 31, 2017
Previous Editions Are Obsolete
City/Cities
Page 11
Report Date: ______________
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 and Mandatory Roles 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
A.
*Job Title : Manager or CEO
*Salutation :
Work Address
*Line 1 :
Line 1 :
Line 2 :
Line 2 :
*First Name :
*City :
City :
Middle Name :
County :
County :
*Last Name :
*State :
*Employment Type :
*Country :
Country :
*Role(s) :
*Phone :
Phone :
Ext. :
Fax :
Cell :
Fax :
B.
*Job Title : Chairperson
*Zip :
Cell :
State :
*Email :
Email :
*Line 1 :
Line 1 :
Zip :
*Salutation :
Line 2 :
Line 2 :
*First Name :
*City :
City :
Middle Name :
County :
*Last Name :
*State :
*Employment Type :
*Country :
Country :
*Role(s) :
*Phone :
Phone :
Ext. :
Fax :
Cell :
Fax :
C.
*Job Title : Vice Chairperson
County :
*Zip :
Cell :
State :
*Email :
Email :
*Line 1 :
Line 1 :
*Salutation :
Line 2 :
Line 2 :
*First Name :
*City :
City :
Middle Name :
County :
County :
*Last Name :
*State :
*Employment Type :
*Country :
Country :
*Role(s) :
*Phone :
Phone :
Ext. :
Fax :
Cell :
Fax :
*Zip :
Cell :
Email :
OMB No. 3133-0004
State :
Zip :
Zip :
Email :
NCUA Profile Form 4501A
Effective March 31, 2017
Previous Editions Are Obsolete
Page 12
Report Date: ______________
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 and Mandatory Roles 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
D.
*Job Title : Board Secretary
Work Address
*Line 1 :
Line 1 :
*Salutation :
Line 2 :
Line 2 :
*First Name :
*City :
City :
Middle Name :
County :
*Last Name :
*State :
*Employment Type :
*Country :
Country :
*Role(s) :
*Phone :
Phone :
Ext. :
Fax :
Cell :
Fax :
County :
*Zip :
Cell :
State :
Email :
Email :
*Line 1 :
Line 1 :
*Salutation :
Line 2 :
Line 2 :
*First Name :
*City :
City :
Middle Name :
County :
*Last Name :
*State :
*Employment Type :
*Country :
*Role(s) :
*Phone :
E.
*Job Title : Board Treasurer
Fax :
F.
*Job Title : Board Member
Zip :
County :
*Zip :
State :
Zip :
Country :
Cell :
Phone :
Ext. :
Fax :
Cell :
Email :
Email :
*Line 1 :
Line 1 :
*Salutation :
Line 2 :
Line 2 :
*First Name :
*City :
City :
Middle Name :
County :
County :
*Last Name :
*State :
*Employment Type :
*Country :
Country :
*Role(s) :
*Phone :
Phone :
Ext. :
Fax :
Cell :
Fax :
*Zip :
Cell :
Email :
OMB No. 3133-0004
State :
Zip :
Email :
NCUA Profile Form 4501A
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Page 13
Report Date: ______________
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
G.
*Job Title : Board Member
Work Address
*Line 1 :
Line 1 :
*Salutation :
Line 2 :
Line 2 :
*First Name :
*City :
City :
Middle Name :
County :
*Last Name :
*State :
*Employment Type :
*Country :
Country :
*Role(s) :
*Phone :
Phone :
Ext. :
Fax :
Cell :
Fax :
County :
*Zip :
Cell :
State :
Zip :
Email :
Email :
*Line 1 :
Line 1 :
*Salutation :
Line 2 :
Line 2 :
*First Name :
*City :
City :
Middle Name :
County :
*Last Name :
*State :
*Employment Type :
*Country :
Country :
*Role(s) :
*Phone :
Phone :
Ext. :
Fax :
Cell :
H.
*Job Title : Board Member
Fax :
I.
*Job Title : Board Member
*Salutation :
County :
*Zip :
Cell :
State :
Email :
Email :
*Line 1 :
Line 1 :
Line 2 :
Line 2 :
*First Name :
*City :
City :
Middle Name :
County :
County :
*Last Name :
*State :
*Employment Type :
*Country :
Country :
*Role(s) :
*Phone :
Phone :
Ext. :
Fax :
Cell :
Fax :
*Zip :
Cell :
Email :
OMB No. 3133-0004
State :
Zip :
Zip :
Email :
NCUA Profile Form 4501A
Effective March 31, 2017
Previous Editions Are Obsolete
Page 14
Report Date: ______________
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
J.
*Job Title : Credit Committee Chairperson
*Salutation :
Work Address
*Line 1 :
Line 1 :
Line 2 :
Line 2 :
*First Name :
*City :
City :
Middle Name :
County :
County :
*Last Name :
*State :
*Employment Type :
*Country :
*Role(s) :
*Phone :
Fax :
K.
*Zip :
State :
Country :
Cell :
Phone :
Ext. :
Fax :
Cell :
Email :
Email :
*Line 1 :
Line 1 :
*Salutation :
Line 2 :
Line 2 :
*First Name :
*City :
City :
Middle Name :
County :
County :
*Job Title : Credit Committee Member
Zip :
*Last Name :
*State :
*Employment Type :
*Country :
Country :
*Role(s) :
*Phone :
Phone :
Ext. :
Fax :
Cell :
Fax :
L.
*Job Title : Credit Committee Member
*Zip :
Cell :
State :
Email :
Email :
*Line 1 :
Line 1 :
*Salutation :
Line 2 :
Line 2 :
*First Name :
*City :
City :
Middle Name :
County :
County :
*Last Name :
*State :
*Employment Type :
*Country :
Country :
*Role(s) :
*Phone :
Phone :
Ext. :
Fax :
Cell :
Fax :
*Zip :
Cell :
Email :
OMB No. 3133-0004
State :
Zip :
Zip :
Email :
NCUA Profile Form 4501A
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Report Date: ______________
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
*Job Title : Supervisory Committee Chairperson
M.
*Salutation :
Work Address
*Line 1 :
Line 1 :
Line 2 :
Line 2 :
*First Name :
*City :
City :
Middle Name :
County :
County :
*Last Name :
*State :
*Employment Type :
*Country :
Country :
*Role(s) :
*Phone :
Phone :
Ext. :
Fax :
Cell :
Fax :
*Zip :
Cell :
State :
Zip :
Email :
Email :
*Line 1 :
Line 1 :
*Salutation :
Line 2 :
Line 2 :
*First Name :
*City :
City :
Middle Name :
County :
*Last Name :
*State :
*Employment Type :
*Country :
Country :
*Role(s) :
*Phone :
Phone :
Ext. :
Fax :
Cell :
*Job Title : Supervisory Committee Member
N.
Fax :
*Job Title : Supervisory Committee Member
O.
*Salutation :
County :
*Zip :
Cell :
State :
Email :
Email :
*Line 1 :
Line 1 :
Line 2 :
Line 2 :
Zip :
*First Name :
*City :
City :
Middle Name :
County :
County :
*Last Name :
*State :
*Employment Type :
*Country :
Country :
*Role(s) :
*Phone :
Phone :
Ext. :
Fax :
Cell :
Fax :
*Zip :
Cell :
Email :
OMB No. 3133-0004
State :
Zip :
Email :
NCUA Profile Form 4501A
Effective March 31, 2017
Previous Editions Are Obsolete
Page 16
Report Date: ______________
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
P.
Work Address
*Job Title :
*Line 1 :
Line 1 :
*Salutation :
Line 2 :
Line 2 :
*First Name :
*City :
City :
Middle Name :
County :
County :
*Last Name :
*State :
*Employment Type :
*Country :
Country :
*Role(s) :
*Phone :
Phone :
Ext. :
Fax :
Cell :
Fax :
Q.
*Zip :
Cell :
State :
Email :
Email :
*Job Title :
*Line 1 :
Line 1 :
*Salutation :
Line 2 :
Line 2 :
*First Name :
*City :
City :
Middle Name :
County :
County :
*Last Name :
*State :
*Employment Type :
*Country :
*Role(s) :
*Phone :
Fax :
R.
*Zip :
State :
Zip :
Zip :
Country :
Cell :
Phone :
Ext. :
Fax :
Cell :
Email :
Email :
*Job Title :
*Line 1 :
Line 1 :
*Salutation :
Line 2 :
Line 2 :
*First Name :
*City :
City :
Middle Name :
County :
County :
*Last Name :
*State :
*Employment Type :
*Country :
Country :
*Role(s) :
*Phone :
Phone :
Ext. :
Fax :
Cell :
Fax :
*Zip :
Cell :
Email :
OMB No. 3133-0004
State :
Zip :
Email :
NCUA Profile Form 4501A
Effective March 31, 2017
Previous Editions Are Obsolete
Page 17
Report Date: ______________
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 :
*Employment Type :
B.
*Role : Profile Information Contact
*Job Title :
*Employment Type :
C.
*Role : Primary Patriot Act Contact
*Job Title :
*Employment Type :
D.
*Role : Secondary Patriot Act Contact
*Job Title :
*Employment Type :
E.
*Role : Third Patriot Act Contact (Optional)
*Job Title :
*Employment Type :
F.
*Role : Fourth Patriot Act Contact (Optional)
*Job Title :
*Employment Type :
G.
*Role : Primary Emergency Contact
*Job Title :
*Employment Type :
H.
*Role : Secondary Emergency Contact
*Job Title :
*Employment Type :
I.
*Role : Information Security Contact
*Job Title :
*Employment Type :
OMB No. 3133-0004
*Salutation :
Work Email :
*First Name :
Home Email :
Middle Name :
*Work Phone :
*Last Name :
Extension :
*Salutation :
Work Email :
*First Name :
Home Email :
Middle Name :
*Work Phone :
*Last Name :
Extension :
*Salutation :
Work Email :
*First Name :
Home Email :
Middle Name :
*Work Phone :
*Last Name :
Extension :
*Salutation :
Work Email :
*First Name :
Home Email :
Middle Name :
*Work Phone :
*Last Name :
Extension :
*Salutation :
Work Email :
*First Name :
Home Email :
Middle Name :
*Work Phone :
*Last Name :
Extension :
*Salutation :
Work Email :
*First Name :
Home Email :
Middle Name :
*Work Phone :
*Last Name :
Extension :
*Salutation :
Work Email :
*First Name :
Home Email :
Middle Name :
*Work Phone :
*Last Name :
Extension :
*Salutation :
Work Email :
*First Name :
Home Email :
Middle Name :
*Work Phone :
*Last Name :
Extension :
*Salutation :
Work Email :
*First Name :
Home Email :
Middle Name :
*Work Phone :
*Last Name :
Extension :
NCUA Profile Form 4501A
Effective March 31, 2017
Previous Editions Are Obsolete
Page 18
Report Date: ______________
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
Physical Address
Mailing Address
*Line 1 :
*Line 1 :
*Site Name :
Line 2 :
Line 2 :
*Operational Status :
*City :
*City :
County :
County :
*Is Main Office : Yes
*Phone Number :
Fax :
Ext. :
*Hours of Operation :
*State :
*Zip :
*Country :
*State :
*Zip :
*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
*Phone Number :
Fax :
County :
Ext. :
*State :
*Hours of Operation :
County :
*Zip :
*Country :
*Site Function(s) :
*State :
*Zip :
*Country :
Disaster Recovery Location
C. Identify the Vital Records Center information in this section. (Required by NCUA's Rules and Regulation Part 749)
*Site Type :
*Line 1 :
*Line 1 :
*Site Name :
Line 2 :
Line 2 :
*Operational Status :
*City :
*City :
*Is Main Office : No
*Phone Number :
Fax :
County :
Ext. :
*State :
*Hours of Operation :
County :
*Zip :
*Country :
*Site Function(s) :
*State :
*Zip :
*Country :
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 :
*Phone Number :
Ext. :
*State :
*Hours of Operation :
*Country :
*Site Function(s) :
OMB No. 3133-0004
County :
*Zip :
*State :
*Zip :
*Country :
Location of Records
NCUA Profile Form 4501A
Effective March 31, 2017
Previous Editions Are Obsolete
Page 19
| File Type | application/pdf |
| Author | AMBER GRAVIUS |
| File Modified | 2016-12-21 |
| File Created | 2016-12-20 |