FR Y-3 Sections 3(a)(3) and 3(a)(5)

DRAFT

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

January 31, 2021

Board of Governors of the Federal Reserve System

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

Corporate Title of Applicant

Street Address

City

State

Zip Code

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

Hereby applies to the Board pursuant to:
(1) Section 3(a)(1) of the Bank Holding Company Act of 1956, as amended, (‘‘BHC Act’’—12 U.S.C. §1842), under ‘‘Procedures for
other bank acquisition proposals’’ as described in section 225.15 of Regulation Y;
(2) Section 3(a)(3) of the BHC Act, under ‘‘Procedures for other bank acquisition proposals’’ as described in section 225.15 of
Regulation Y; or
(3) Section 3(a)(5) of the BHC Act, under ‘‘Procedures for other bank acquisition proposals’’ as described in section 225.15 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

_____________________________________________________________________
Corporate Title of Target Institution

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

_____________________________________________________________________
Street Address

Yes
As required by the General Instructions, a letter justifying
the request for confidential treatment is included.

_______________________________ ________________ ____________________
City
State
Zip Code

The information for which confidential treatment is being
sought is separately bound and labeled "Confidential."

_____________________________________________________________________
Corporate Title of Additional Target Institution (If Applicable)

No

_____________________________________________________________________'
Street Address
_______________________________ ________________ ____________________
City
State
Zip Code

60.5

50

Public reporting burden for this collection of information for applications filed pursuant to section 3(a)(1) of the BHC Act are estimated to average 53 hours per response while applications
filed pursuant to section 3(a)(3) or section 3(a)(5) of the BHC Act are estimated to average 63.5 hours per response, including the time to gather and maintain data in the required form, to
review instructions and to complete the information collection. The Federal Reserve may not conduct or sponsor, and an organization is not required to respond to, a collection of information unless it displays a currently valid OMB control number. 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.

03/2015

DRAFT

FR Y-3
Page 2 of 2

Name, title, address, telephone number, and facsimile number of person(s) to whom inquiries concerning this application 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 application 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
application, that the applicant 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
applicant and the involved individual consent to public release of
any such information, except to the extent set forth in a written
request by the applicant 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 application 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

________________________________
E-mail Address

03/2011