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

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FS Form 3144 - page 1 of 3

OMB No. 1530-0001

Minority Bank Deposit Program Financial Institution Certification
Form For Admission
I am applying for participation in the Minority Bank Deposit Program (MDBP) administered by the U.S.
Department of the Treasury, Bureau of the Fiscal Service.

1 Institution Name:
Address:
City:

State:

2 Telephone:

Zip Code:

Fax:

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:

if yes please complete the number of shares below

Yes

No

number
of shares

Hispanic or Latino Ethnicity
Black or African American
American Indian or Alaska Native

number
of shares

Native Hawaiian or Other Pacific Islander
Asian
White

B) Women-Owned Bank or Savings and Loans:

if yes please complete the number of shares below

Yes

No

number
of shares

Hispanic or Latino Ethnicity
Black or African American
American Indian or Alaska Native
C) Low-Income Credit Union designated by the
National Credit Union Administration:

5 Total Shares:

number
of shares

Native Hawaiian or Other Pacific Islander
Asian
White
Yes

No
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.)

FS Form 3144

Department of the Treasury | Bureau of the Fiscal Service

April 27, 2016

FS Form 3144 - MBDP Financial Institution Certification Form for Admission - page 2 of 3
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 Fiscal Service
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 the Fiscal Service 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 the Fiscal Service, it shall return such funds to the Fiscal
Service and shall reimburse the Fiscal Service 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 the Fiscal Service.
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.
Affix Bank or
Notary Public Seal
not valid
without seal

Signature:
Print Name:
Title:
Date:
U.S. Department of the Treasury
Bureau of the Fiscal Service
Bank, Policy, and Oversight Division
401 14th Street, S.W., Room 317
Washington, DC 20227

FS Form 3144

Department of the Treasury | Bureau of the Fiscal Service

April 27, 2016

FS Form 3144 - MBDP Financial Institution Certification Form for Admission - page 3 of 3
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
group; 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 womern 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 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 Fiscal 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 45 minutes per respondent or recordkeeper,
depending on individual circumstances. However, you are not required to provide information requested
unless a valid OMB control number is displayed on the form. Comments concerning the accuracy of this
burden estimate and suggestions for reducing this burden should be directed to the Bureau of the Fiscal
Service, Forms Management Officer, Parkersburg, WV 26106-1328. DO NOT SEND completed form this
address, send to the address shown on page 2.

FS Form 3144

Department of the Treasury | Bureau of the Fiscal Service

April 27, 2016