Application and Related Forms

OMB#3170-0037
Expiration Date: XX/XX/20XX
1700 G Street NW, Washington, DC 20552

APPLICATION TO SERVE AS A SMALL ENTITY REPRESENTATIVE
Consumer Financial Protection Bureau

The Consumer Financial Protection Bureau (CFPB) may obtain input from small businesses
and other entities that are likely to be directly affected by a regulation that the CFPB may issue.
Under the law, when a rule under development may have a significant economic impact on a
substantial number of small entities, representatives from the CFPB, the Chief Counsel for
Advocacy of the Small Business Administration, and the Office of Management and Budget’s
Office of Information and Regulatory Affairs form a Small Business Review Panel (SBREFA
Panel or Panel). The Panel then meets with a selected group of representatives from small
businesses and other entities.
To prepare for the Panel meeting, the CFPB provides all small entity representatives
(SER) with an outline describing the proposal, as well as options or alternatives under
consideration. Then, during the Panel meeting, the CFPB reviews these materials with the
SER's and solicits information from the representatives. The representatives discuss and provide
the Panel with important feedback on the potential costs and other economic impacts of
complying with the proposed regulations under consideration and potential regulatory
alternatives to minimize these impacts while accomplishing the objectives of applicable statutes.
During the Panel meeting or in separate consultation meetings with representatives, the CFPB
may also solicit feedback on how the proposals under consideration may impact the cost of credit
for small entities and ways to minimize any such impact. Small entity representatives will also
have an opportunity to provide feedback through the submission of written comments.
The CFPB is looking for individual representatives of small businesses, small non-profit
organizations, or small governments who are interested in participating in future Panel
meetings and providing feedback on the potential economic impacts of proposed regulations
under consideration. The information provided in this form allows the CFPB to compile a list
of representatives from small entities who are potentially eligible to participate in a future
Panel.
If you are interested in participating, please provide us with the information listed below.
Some respondents may then be contacted and invited to participate in a Panel outreach
meeting or other CFPB outreach events.
ABOUT YOU:
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Name
Title
E-Mail
Phone number

ABOUT YOUR BUSINESS OR ORGANIZATION:
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Application to Serve as a Small Entity Representative, Consumer Financial Protection Bureau

OMB#3170-0037
Expiration Date: XX/
XX/20XX
1700 G Street NW, Washington, DC 20552

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Name
Address (City, State, Zip Code)
Website (if applicable)
Type (you may choose more than one) [drop-down or list with boxes to be checked]
o Commercial Bank
o Credit Union
o Savings Bank/Savings Institution
o Mortgage Lender
o Mortgage Brokerage
o Mortgage Servicer
o Other Brokerage
o Payday Lender
o Private Education Lender
o Student Loan Servicer
o Automobile Finance Company
o Other Consumer Finance Company
o Credit Reporting Agency
o Debt Collector
o Money Transmitter
o Check Casher
o Other Money Services Business
o Debt Relief/Settlement Company
o Prepaid Value Issuer or Program Manager
o Nonbank Credit Card Issuer
o Payment Processor
o Payment Network
o Non-Profit Organization
o Governmental Entity
o Other (please specify)

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Total Assets (for depository institutions) (determine by averaging the assets (defined
according to the Federal Financial Institutions Examination Council 034 call report form)
reported on the institution’s four quarterly financial statements for the preceding year)

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Total Revenue (for non-depository institutions) (determine by averaging the revenues or
receipts reported on IRS tax return forms over last three fiscal years; include revenue of
any affiliates in this calculation)

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Number of Employees

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Scope and Nature of Business Activities (e.g., types of products or services offered)

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Names and Description of Affiliated Entities (entities are affiliates of each other when
one controls or has the power to control the other, or a third party or parties controls or
has the power to control both)
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Application to Serve as a Small Entity Representative, Consumer Financial Protection Bureau

OMB#3170-0037
Expiration Date: XX/
XX/20XX
1700 G Street NW, Washington, DC 20552

-

Memberships or Affiliations with Trade Associations or Other Organizations

Thank you for providing this information.
Privacy Act Notice
The information that you provide will be used by the Consumer Financial Protection Bureau
(CFPB) to determine qualifications, suitability, and availability for service as a small entity
representative to provide feedback to a Small Business Review Panel (SBREFA panel). The
information you provide or other information we collect may be shared with other agencies,
including the Small Business Administration (SBA) and the Office of Management and Budget,
for purposes directly related to the activities of the SBREFA panels. The information collected
will be for annual reports on advisory boards, bodies, panels, including SBREFA panels,
committees or other similar groups. The information will be used by and disclosed to employees,
contractors, agents, and others authorized by the CFPB to receive this information to assist in
related activities. Additionally, the names and biographies of panel members will be released to
the public. The information may also be disclosed to:
• the office of the President or a member of Congress;
• to a court, a party in litigation, a magistrate, an adjudicative body or
administrative tribunal in the course of a proceeding, or the Department of
Justice; and
• to other federal or state agencies or regulatory authorities for enforcement and
statutory purposes.
The collection of this information is authorized by Pub. L. No. 111-203, Title X, sections 1011,
1012, codified at 12 U.S.C. §§ 5491, 5492.
Paperwork Reduction Act
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a valid OMB control number. The OMB control number for this collection
is 3170-0037. It expires on MM/DD/YYYY. The time required to complete this information collection is estimated to average
approximately 10 minutes per response. The Obligation to respond to this form is voluntary. Comments regarding this collection
of information, including the estimated response time, suggestions for improving the usefulness of the information, or
suggestions for reducing the burden to respond to this collection should be submitted to Bureau at the Consumer Financial
Protection Bureau (Attention: PRA Office), 1700 G Street NW, Washington, DC 20552, or by email to PRA_Comments@cfpb.gov.

The Consumer Financial Protection Bureau (CFPB) prohibits discrimination in all its programs and activities on the basis of race,
color, national origin, gender, religion, age, political beliefs, sexual orientation, marital or family status, parental status or
protected genetic information. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative
means of communication of program information (Braille, large print, audiotape, etc.) should contact Liza Strong, Labor and

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Application to Serve as a Small Entity Representative, Consumer Financial Protection Bureau

OMB#3170-0037
Expiration Date: XX/
XX/20XX
1700 G Street NW, Washington, DC 20552

Employee Relations, Office of Human Capital. To file a complaint of discrimination, contact the Treasury Department at 202622-9252. CFPB is an equal opportunity provider and employer.

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Application to Serve as a Small Entity Representative, Consumer Financial Protection Bureau