Form Independent Direct Independent Direct Federal Home Loan Bank Independent Director Annual Certi

FEDERAL HOME LOAN BANK
INDEPENDENT DIRECTOR
ANNUAL CERTIFICATION FORM
Full name: _____________________________________________________________
Federal Home Loan Bank of: ______________________________________________
Every year, each incumbent independent Federal Home Loan Bank (Bank) director must certify that
he or she continues to meet all of the following requirements:



United States citizen
Bona fide resident of a state in the geographic district of the Bank on whose board you serve
o your principal residence is located in that geographic district OR
o you own or lease a second residence in the district and are employed in the district



During your term of office, you and your spouse may not:
o serve as an officer of any Federal Home Loan Bank
o serve as an officer, employee, or director of any member or subsidiary of a member of the
Bank you serve, or any holding company that controls one or more members of the Bank
you serve if the assets of all such members constitute 35 percent or more of the assets of the
holding company, on a consolidated basis
o serve as an officer, employee, or director of any recipient of advances from the Bank you
serve, or any holding company that controls one or more recipients of advances from the
Bank you serve if the assets of all such recipients constitute 35 percent or more of the assets
of the holding company, on a consolidated basis



To be designated a public interest director, you must have more than four years experience
representing consumer or community interests on banking services, credit needs, housing, or
consumer financial protections
If you are not designated as a public interest director, you must have knowledge or experience in
one of the following: auditing and accounting, derivatives, financial management, organizational
management, project development, risk management practices, or the law.



By executing this form, you are certifying that you continue to meet these
requirements and that the director application form you submitted previously, or
any amended certification form you submitted previously, is true, correct, and
complete to the best of your knowledge.

Expires ##/##/2021
OMB No. 2590-0006

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Please check one box:
No changes have occurred.
Changes have occurred to my responses in these sections of my Form:
Personal information:

Eligibility information, including conflicts of interest:

Commitment to serve:

Personal integrity:

Independence:

Other changes:

Dated: ___________________________________
Signature: ________________________________________________

Privacy Act Statement: In accordance with the Privacy Act (5 U.S.C. 552a), the following notice is provided. This information is solicited
under authority of 12 U.S.C. 1427(a) and (b); and 12 CFR 1261.5, 1261.7, and 1261.10 to 1261.13. Furnishing the information on this form is
voluntary, but failure to do so may result in you not meeting the statutory and regulatory eligibility requirements to serve as an independent
director. The purpose of this information is to facilitate the timely determination of your eligibility to serve as an independent director.
Information may be disclosed in accordance with the routine uses identified in FHFA-System of Records Notice FHFA-8 Federal Home Loan
Bank Directors, which may be found at https://www.fhfa.gov/SupervisionRegulation/Rules/Pages/Privacy-Act-of-1974-System-of-RecordsNotice-of-the-Establishment-of-New-Systems-of-Records.aspx.
Paperwork Reduction Act Statement: Notwithstanding any other provision of the law, no person is required to respond to, nor shall any
person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act,
unless that collection of information displays a currently valid OMB Control Number.

Expires ##/##/2021
OMB No. 2590-0006

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