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

FEDERAL HOME LOAN BANK INDEPENDENT DIRECTOR ANNUAL CERTIFICATION FORM (REVISED)
INSTRUCTIONS
The Federal Home Loan Bank of [TO BE COMPLETED BY EACH BANK] (Bank) is required by law to solicit
information from its incumbent directors annually to verify that each director remains in compliance
with the applicable statutory and regulatory eligibility requirements. Your responses to the questions
on this Federal Home Loan Bank Independent Director Annual Certification Form will assist the Bank in
verifying that you continue to meet the eligibility requirements that apply to the independent
directorship in which you are currently serving.
Please complete and execute this Form and return it to the Bank on or before [MARCH 1, {CURRENT
YEAR} (or, if 3/1 is not a business day, THE NEXT BUSINESS DAY FOLLOWING 3/1)]. If you fail to submit
a completed and executed Form by that date, or if you submit a Form that does not adequately
demonstrate that you continue to meet all applicable eligibility requirements, the Bank may determine
that you are ineligible to serve, in which case the Bank would be required by law to declare your
directorship vacant.
You are eligible to serve as an independent director of the Bank only if you meet all of the following
requirements:
•

You are a citizen of the United States.

•

You are a bona fide resident of the Bank District, as determined by meeting either one of the
following two sets of criteria:
o Your principal residence is located in the Bank District; or
o You both:
 Own or lease in your own name a residence in the Bank District; and
 Are employed in a voting state in the Bank District.

•

Neither you nor your spouse are:
o An officer of any Federal Home Loan Bank; or
o An officer, employee, or director of any member of, or recipient of advances from, the
Bank. For purposes of this prohibition:
 “Advances” includes any form of lending, regardless of whether it is
denominated as an “advance”; and
 “Member” and “recipient of advances” include the institution itself and the
institution’s holding company, except where the assets of all members or all
recipients of advances constitute less than 35 percent of the assets of the
holding company, on a consolidated basis.

These eligibility requirements may be found in sections 7(a) and (b) of the Federal Home Loan Bank Act
(Bank Act), 12 U.S.C. 1427(a) and (b), and in FHFA’s regulations at 12 CFR 1261.5(c) and 1261.10.

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FEDERAL HOME LOAN BANK INDEPENDENT DIRECTOR ANNUAL CERTIFICATION FORM (REVISED)
YOUR PERSONAL INFORMATION
Please provide your personal information as indicated in Questions 1 –4.
1. Full Name:
2. Other Names Currently or Formerly Used, or Known by:
3. Contact Information:
•
•
•

Phone number (leave room for multiple; indicate home, office, or cell):
E-mail address:
Mailing address: Number/Street (or PO Box), City, State, Zip Code

4. Current Employment, if Applicable:
•
•
•

Current employer:
Your title or position:
Address of your place of employment: Number/Street, City, State, Zip Code

ELIGIBILITY REQUIREMENTS
Please answer Questions 5 – 8, regarding your eligibility to serve as an independent director in full.
CITIZENSHIP AND RESIDENCY
You must meet the legal requirements as to U.S. citizenship and Bank District residency to be eligible
for nomination for an independent directorship.
5. Citizenship. Are you a citizen of the United States? ___ Yes ___ No
6. Residency.
A. Do you own or lease a residence within the Bank District? ___ Yes ___ No
If you answered No to Question 6A, you do not meet the residency requirement.
B. If you answered Yes to Question 6A, please provide the street address of your residence
within the Bank District: (Number/Street, City, State, Zip Code)
C. Is the address provided in response to Question 6B your principal residence?
___ Yes ___ No
If you answered Yes to Question 6C, you meet the residency requirement.
If you answered No to Question 6C, you may still meet the residency requirement if you
are employed within the Bank District. Please continue with Question 6D to indicate
your in-District employment status.
D. Are you employed within the Bank District? ___ Yes ___ No
E. If you answered Yes to Question 6D, please identify your in-District employer:
o

___ Check if your in-District employment information is the same as that
entered in response to Question 4.

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FEDERAL HOME LOAN BANK INDEPENDENT DIRECTOR ANNUAL CERTIFICATION FORM (REVISED)
o

___ Check if your in-District employment information is different from that
entered in response to Question 4, then provide the following information:
 Name of your in-District employer:
 Your title or position:
 Address of your place of employment: Number/Street, City, State,
Zip Code

INDEPENDENCE
The information you provide below will enable the Bank to determine whether you continue to
meet the independence requirements.
7. Employment by a Federal Home Loan Bank.
A. Are you or your spouse an officer or employee of any Federal Home Loan Bank?
___ Yes ___ No
B. If you answered Yes to Question 7A, please provide the following information for each
such position held by you or your spouse:
o Name of the person holding the position:
o Federal Home Loan Bank of:
o Title or position:
o Dates held:
8. Employment by a Bank Member, Housing Associate, or Holding Company.
A. Are you or your spouse an officer, director, or employee of a member of the Bank, an
entity certified as a housing associate of the Bank, or a holding company that controls
one or more members or housing associates of the Bank? ___ Yes ___ No
B. If you answered Yes to Question 8A, please provide the following information for each
such position held by you or your spouse:
o
o
o

o
o
o

Name of the person holding the position:
Name of the employer:
Check the appropriate response below to indicate whether the employer is:
 ___ a member
 ___ a holding company of a member
 ___ a housing associate
 ___ a holding company of a housing associate
Position or Title:
Dates held:
If the employer is a holding company:
 Indicate the total assets of the holding company;
 Indicate the total assets of each member or housing associate of the
Bank controlled by the holding company; and
 Provide, or direct the Bank to, documentation to support those
amounts.

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FEDERAL HOME LOAN BANK INDEPENDENT DIRECTOR ANNUAL CERTIFICATION FORM (REVISED)
By executing this Form, you are certifying that the information you have provided is true, correct, and
complete to the best of your knowledge and that you understand that you have a continuing
obligation to inform the Bank of any facts that may call into question your eligibility or ability to serve
as a Bank director. You further acknowledge that the Bank and the Federal Housing Finance Agency
may perform a background check on you, including without limitation regarding any information
disclosed herein.
Signature:

Dated:

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 your not meeting the statutory and regulatory eligibility requirements to continue to
serve as a Federal Home Loan Bank independent director. The purpose of this information is to facilitate
the timely determination of your eligibility to continue to serve as an independent director. Information
may be disclosed in accordance with the routine uses identified in FHFA-System of Records Notice FHFA8 Federal Home Loan Bank Directors, which may be found at
https://www.fhfa.gov/AboutUs/FOIAPrivacy/Documents/SORNs/FHFA8%20Federal%20Home%20Loan%20Bank%20Directors.pdf.
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.
OMB No. 2590-0006
Expires ##/##/20##

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