Confirmation of Participation

11/22/22, 3:30 PM

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ECIP Additional Information Request: AIR-498

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ECIP Additional Information Request

AIR-498
Status

Applicant's Name

Information Requested

test - GH 03/24

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INSTRUCTIONS:
Please reference the following instructions to complete the fields below. You are required to complete the fields marked with an asterisk
(*) unless otherwise indicated.
Question 1: Confirm the Applicant's intention to proceed with closing or to withdraw from the program by selecting the relevant value
from the drop-down menu.
• If

you select "Intends to Withdraw" from the drop-down menu, respond to Questions 1 and 6 only. 
• If you select "Intends to Proceed" from the drop-down menu, respond to Questions 1 - 6.
Question 2: Enter the amount the Applicant intends to issue to Treasury, rounded down to the nearest thousand dollar increment (e.g.,
$453,000 not
$453,211). This amount must be equal to or less than the amount the Applicant was approved for, which is shown in the "Maximum
Approved Amount" field.
Question 3: Confirm whether the Applicant intends to issue preferred stock or subordinated debt to Treasury in connection with its
participation in the program by selecting the relevant value from the drop-down menu. An institution must issue preferred stock if it is
feasibly able to do so. Only institutions that cannot feasibly issue preferred stock, such as mutual institutions, Subchapter S
corporations, and credit unions, may instead issue subordinated debt.
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Question 4: Select three unique time periods during which you would prefer to close by selecting the relevant values from the dropdown menus. Your closing window preferences do not need to be chronological - that is, your 2nd choice does not need to be later
than your 1st choice and your 3rd choice does not need to be later than your 2nd choice. Before selecting your preferences, please
review the closing documents posted on Treasury's website and consider your ability to fulfill the closing conditions, including obtaining
any necessary shareholder or board of director approvals, before your preferred closing window. Treasury will make an effort to
accommodate your preferences but reserves the right to select a different closing date if necessary or appropriate in Treasury's
discretion.
Question 5: Provide the name, title, and contact information for the person you wish to designate as your primary point of contact
during the closing process, who may be an individual from the Applicant or your legal counsel.
Question 6: Certify that the information you provided in response to the questions above is true and correct to the best of your
knowledge by having the Applicant's CEO, CFO, or another authorized representative type their name in the "Authorized
Representative" field and their title into the "Title of Authorized Representative" field.
Click the "Submit" button in the top right corner of the screen to send your response to Treasury.
Note: If you missed any fields, please go back and make your corrections. Once you have done so, click "Try Again" and REFRESH
your browser.

Information
ECIP Additional Information Request Name

Emergency Capital Investment Application

AIR-498

EC-1328 (/cares/s/emergency-capital-investmentapplication/a1Ft000000Xyym2EAB/ec1328)

Type

Applicant's Name

Closing

test - GH 03/24

Status

Date Information Requested

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Information Requested

2/21/2022 9:10 AM

Applicant Response
1. Application Intention*

3. Question*

If Applicant intends to proceed, does Applicant intend to issue preferred
stock or subordinated debt to Treasury in connection with its participation in
the Program?

Applicant Issued Instrument (i.e., Preferred Stock or Subordinated Debt).
Applicant Issued Instrument

2. Intended Issuance Amount*

Maximum Approved Amount

$2,400,000

4. Preferred Closing Windows
Preferred Closing Window: 1st Choice*

Preferred Closing Window: 3rd Choice*

Preferred Closing Window: 2nd Choice*

5. Closing Primary Contact
Closing Contact Name*

Closing Contact State/Territory*

Company

Closing Contact Zip Code*

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Title/Role*

Closing Contact Email*

Closing Contact Street Address*

Closing Phone Number*

Closing Contact City*

6. Certification
Certification*

By typing my name below, I hereby certify that I have the authority to submit this response for the Applicant on whose behalf I am signing, and that all current
representations made and information provided are true and correct to the best of my knowledge. I further acknowledge that any false statements made to the
Department of the Treasury can result in criminal prosecution under 18 U.S.C. 1001, 15 U.S.C. 645, and other provisions and imposition of civil money penalties
under 31 U.S.C. 3729.

Authorized Representative

Title of Authorized Representative*

Date Information Received

Paperwork Reduction Act Notice

Paperwork Reduction Act Notice.

OMB Approval No. 1505-0267

Expiration Date: June 30, 2022

The information collected will be used for the U.S. Government to process requests for support. The estimated burden associated with this collection of
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information is 15 minutes for this form response. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should
be directed to the Office of Privacy, Transparency and Records, Department of the Treasury, 1500 Pennsylvania Ave., N.W., Washington, D.C. 20220. DO NOT
send the form to this address. 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 control number assigned by OMB.

You responded on and the record is now locked. Please contact the ECIP Team if you need assistance: ECIP@treasury.gov.

Thank You!

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