Form FR Y-3N FR Y-3N Notification to Become a Bank Holding Company and/or Acq

FR Y-3N
OMB Number 7100-0121
Approval expires July 31, 2018
Page 1 of 2

Board of Governors of the Federal Reserve System

Notification to Become a Bank Holding Company
and/or Acquire an Additional Bank
or Bank Holding Company—FR Y-3N

Corporate Title of Notificant

Street Address

City

State

Zip Code

(Type of organization, such as corporation, partnership, business trust, association, or trust)

Hereby provides the Board with a notice pursuant to:
(1) Section 3(a)(5)(C) of the Bank Holding Company Act of 1956, as amended, (‘‘BHC Act’’—12 U.S.C. §1842(a)(5)(C)), under
‘‘Notice procedures for one-bank holding company formations’’ as described in section 225.17 of Regulation Y;
(2) Section 3(a)(3) of the BHC Act, under the ‘‘Expedited action for certain bank acquisitions by well-run bank holding companies’’
as described in section 225.14 of Regulation Y; or
(3) Section 3(a)(5) of the BHC Act, under the ‘‘Expedited action for certain bank acquisitions by well-run bank holding companies’’
as described in section 225.14 of Regulation Y.
for prior approval of the acquisition of direct or indirect ownership, control, or power to vote at least
a class of voting shares or otherwise to control:
Number

(

%) of
Percent

Corporate Title of Bank or Bank Holding Company

Street Address

City

State

Zip Code

Does notificant request confidential treatment for any portion of
this submission?

Yes
As required by the General Instructions, a letter justifying
the request for confidential treatment is included.
The information for which confidential treatment is being
sought is separately bound and labeled "Confidential."

No

Public reporting burden for this collection of information is estimated to average 5 hours for each type of notifcation, including the time to gather and maintain data in the required form, to
review instructions, and to complete the information collection. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden to: Secretary, Board of Governors of the Federal Reserve System, 20th and C Streets, NW, Washington, DC 20551; and to the Office of Management and Budget,
Paperwork Reduction Project (7100-0121), Washington, DC 20503. The Federal Reserve may not conduct or sponsor, and an organization or a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.

01/2018

FR Y-3N
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Name, title, address, telephone number, and facsimile number of person(s) to whom inquiries concerning this notification may be directed:

Name

Name

Title

Title

Street Address

Street Address

City

State

Zip Code

City

Area Code / Phone Number

Area Code / Phone Number

Area Code / FAX Number

Area Code / FAX Number

State

Zip Code

Certification
I certify that the information contained in this notification has
been examined carefully by me and is true, correct, and complete, and is current as of the date of this submission to the best
of my knowledge and belief. I acknowledge that any misrepresentation or omission of a material fact constitutes fraud in the
inducement and may subject me to legal sanctions provided by
18 U.S.C. §1001 and §1007.
I also certify, with respect to any information pertaining to an individual and submitted to the Board in (or in connection with) this
notification, that the notificant has the authority, on behalf of the
individual, to provide such information to the Board and to consent
or to object to public release of such information. I certify that the
notificant and the involved individual consent to public release of
any such information, except to the extent set forth in a written
request by the notificant or the individual, submitted in accordance
with the Instructions to this form and the Board’s Rules Regarding

Signed this

day of
Day

,
Month

Availability of Information (12 C.F.R. Part 261), requesting confidential treatment for the information.
I acknowledge that approval of this notification is in the discretion
of the Board of Governors of the Federal Reserve System (the
“Federal Reserve”). Actions or communications, whether oral,
written, or electronic, by the Federal Reserve or its employees in
connection with this filing, including approval if granted, do not
constitute a contract, either express or implied, or any other obligation binding upon the agency, the United States or any other
entity of the United States, or any officer or employee of the
United States. Such actions or communications will not affect the
ability of the Federal Reserve to exercise its supervisory, regulatory, or examination powers under applicable laws and regulations. I further acknowledge that the foregoing may not be waived
or modified by any employee or agency of the Federal Reserve
or of the United States.

.
Year

Signature of Chief Executive Officer or Designee

Print or Type Name

Title

03/2011