Form 3700/44 Leasing Representations and Certifications

OMB NUMBER: 3064-0072
EXPIRATION DATE: 03/31/2025

FDIC
Contractor
Representations and
Certifications
SUBMITTED BY

CONTRACTOR NAME

FDIC 3700/04A (3-23)

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OMB NUMBER: 3064-0072
EXPIRATION DATE: 03/31/2025

FDIC CONTRACTOR REPRESENTATIONS AND CERTIFICATIONS
TABLE OF CONTENTS
Page
Estimated Reporting Burden..........................................................................................................................

3

Privacy Act Statement....................................................................................................................................

3

1. Certificate of Registration in System for Award Management (SAM)........................................................

4

2. Certificate of Independent Price Determination.........................................................................................

5

3. Contingent Fee Representation.................................................................................................................

6

4. Equal Opportunity Certification..................................................................................................................

6

5. Certification and Disclosure Regarding Payments to Influence Certain Federal Transactions.................

7

6. Representation by Corporations Regarding an Unpaid Delinquent Federal Tax Liability.........................

7

7. Certification Regarding Fair Inclusion of Minorities and Women..............................................................

8

8. Covered Telecommunications Equipment Service .....................................................................................

9

9. Representation Regarding Certain Telecommunications and Video Surveillance Services or Equipment

9

10. Small Business Representation................................................................................................................

11

11. Prohibition on Contracting with Entities that Require Certain Internal Confidentiality Agreements or Statements-Representatio
12
12. Certification Regarding Whistleblower Rights and Remedies

12

13. Signature................................................................................................................................................

13

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OMB NUMBER: 3064-0072
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FDIC CONTRACTOR REPRESENTATIONS AND CERTIFICATIONS
ESTIMATED REPORTING BURDEN
Public reporting burden for this collection of information is estimated to average 45 minutes per response, including
the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden, to the Paper Reduction
Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17th Street, N.W., Washington,
D.C. 20429; and to the Office of Management and Budget, Paperwork Reduction Project (3064-0072), Washington,
D.C. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number.

PRIVACY ACT STATEMENT
The FDIC is authorized to request this information from you by 12 U.S.C. §§ 1819, and 1821. The purpose for
collecting this information is to examine a contractor's eligibility for potential FDIC contract awards. Furnishing the
requested information is voluntary, but failure to provide the requested information in whole or in part may delay or
prohibit you from receiving an FDIC contract. The information provided by individuals is protected by the Privacy
Act, 5 U.S.C. 552a. The information you provide may be provided to appropriate Federal, state, local or foreign law
enforcement authorities; to a court, administrative tribunal, or a party in litigation; to contractors, agents and other
third parties as authorized by law; and in accordance with any of the other routine uses described in the FDIC
Financial Information System (30-64-0012) System of Records available at www.fdic.gov/about/privacy. If you have
questions or concerns about the collection or use of the information, you may contact the FDIC's Chief Privacy
Officer at Privacy@fdic.gov.

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OMB NUMBER: 3064-0072
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FDIC CONTRACTOR REPRESENTATIONS AND CERTIFICATIONS
PREAMBLE:
Contractors receiving awards from the FDIC are subject to the provisions of 12 Code of Federal Regulations
Chapter III, Part 366, which may be found at: http://www.fdic.gov/buying/goods/acquisition/index.html. The
representations and certifications set out in this solicitation / document must be completed by an official authorized
to bind the offeror, and must be returned with its proposal. These representations and certifications concern
matters within the jurisdiction of an agency of the United States, and the making of a false, fictitious, or fraudulent
certification may render the offeror and certifying official subject to prosecution under 18 United States Code §§
1001, 1007, and 1014. (For purposes of these certifications, the Federal Deposit Insurance Corporation (FDIC) is
considered an agency of the United States only with respect to its rights and remedies under Title 18 of the United
States Code). In addition, any misrepresentations or false, fictitious, or fraudulent certifications may render the
offeror and the certifying official subject to administrative remedies available to the FDIC, which include
suspension and/or exclusion from contracting, or termination of the contract, (12 CFR 366.16; 12 CFR Part 367).
The offeror must provide notice to the Contracting Officer, or the FDIC point of contact for the solicitation, within 10
business days of discovery or at any time prior to contract award, if the contractor learns that one or more of its
representations and certifications were erroneous when submitted or have become erroneous by reason of
changed circumstances.
The signature of the offeror in the Signature section of this document constitutes the making of the applicable
representations and certifications.
The applicable representations and certifications will be incorporated by reference into any contract awarded to
the offeror pursuant to this solicitation.
1. CERTIFICATION OF REGISTRATION IN SYSTEM FOR AWARD MANAGEMENT (SAM)
(Applicable to all acquisitions)
a. The offeror certifies that it is registered in the System for Award Management (SAM) at www.sam.gov, and
that all information in SAM is correct, including its socioeconomic-economic status.
Yes

No

An offeror that marks “No” must also complete the certification in paragraph b.
b. The offeror certifies that it is in the process of registering in the System for Award Management
(SAM) at www.sam.gov, and will enter correct information in SAM, including its socioeconomic-economic
status.
Yes

No

c. The socioeconomic-economic groups in SAM are as follows:
Women-Owned Business
Minority-Owned Business
Small Disadvantaged Business
For Minority-Owned Businesses, the ethnic/racial categories are as follows:
Asian-Pacific American Owned
Subcontinent Asian (Asian-Indian) American Owned
Black American Owned
Hispanic American Owned
Native American Owned
Other than one of the preceding
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FDIC CONTRACTOR REPRESENTATIONS AND CERTIFICATIONS
2. CERTIFICATE OF INDEPENDENT PRICE DETERMINATION
(Applicable to acquisitions over $250,000)
a. The offer certifies that:
(1) The prices in this proposal have been arrived at independently, without, for the purposes of restricting
competition, any consultation, communication, or agreement with any other offeror or competitor
relating to (I) those prices, (ii) the intention to submit an offer or (iii) the methods or factors used to
calculate the prices offered;
(2) The prices in this proposal have not been and will not be knowingly disclosed by the offeror, directly or
indirectly, to any other offeror or competitor before contract award unless otherwise required by law;
and
(3) No attempt has been made or will be made by the offeror to induce any other concern to submit or not
to submit a proposal for the purpose of restricting competition.
b. Each signature on the proposal is considered to be a certification by the signatory that the signatory:
(1) Is the person in the offeror's organization responsible within that organization for determining the prices
being offered in this proposal, and that the signatory has not participated and will not participate in any action
contrary to a. (1) through a. (3) above, or
(2) (i) Has been authorized, in writing, to act as agent for the following principals in certifying that those
principals have not participated, and will not participate in any action contrary to subparagraphs a. (1)
through a. (3) above
(insert full name of person(s) in the offeror's organization responsible for determining the prices offered
in this proposal, and the title of his or her position in the offeror's organization.);

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FDIC CONTRACTOR REPRESENTATIONS AND CERTIFICATIONS
(ii) As an authorized agent, certifies that the principals named in subdivision b.(2)(I) above have not participated,
and will not participate I, in any action contrary to subparagraphs a.(1) through a.(3) above; and
(iii) As an agent, has not personally participated, and will not participate, in any action contrary to subparagraphs
a.(1) through a.(3) above. (iii) As an agent, has not personally participated, and will not participate, in any action
contrary to subparagraphs (a)(1) through (a)(3) above.
c. A proposal will not be considered for award where a.(1), a.(3) or b. above has been deleted or modified. If the
offeror deleted or modifies a.(2) above, the offeror must furnish with its proposal a signed statement setting forth in
detail the circumstances of the disclosure.

3. CONTINGENT FEE REPRESENTATION
(Applicable to acquisitions over $250,000, except for the acquisition of commercial items.)
The offeror represents that except for full-time bona fide employees working solely for the offeror, the offeror
has not employed or retained any person or company to solicit or obtain this contract; and
(a) has
(b)
has
has not paid or agreed to pay any person or company employed or retained to solicit or obtain
this contract any commission, percentage, brokerage, or other fee contingent upon or resulting from the award
of this contract. The offeror agrees to provide information relating to this Representation as requested by the
Contracting Officer when either (a) or (b) herein is answered affirmatively. As used herein, “bona fide
employee” means a person employed by an offeror or contractor and subject to the offeror's or the contractor's
supervision and control as to time, place and manner of performance, who neither exerts nor proposes to exert
improper influence to solicit or obtain FDIC contracts nor holds out as being able to obtain any FDIC contract
or contracts through improper influence.
4. EQUAL OPPORTUNITY CERTIFICATION
(Applicable to acquisitions over $10,000)
The offeror represents that:
a. It
has
has not participated in a previous contract or subcontract subject to the Equal
Opportunity clause of this solicitation;
b. It

has

has not filed all required compliance reports; and

c. Representations indicating submission of required compliance reports, signed by proposed
subcontractors, will be obtained before subcontract awards.
The offeror also represents that:
has developed and has on file
has not developed and does not have on file, at each
d. It
establishment, affirmative action programs required by the rules and regulations of the Secretary of
Labor (41 CFR 60-1 and 60-2); or
e. It
has not previously had contracts subject to the written affirmative action programs requirement of
the rules and regulations of the Secretary of Labor.

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FDIC CONTRACTOR REPRESENTATIONS AND CERTIFICATIONS
5. CERTIFICATION AND DISCLOSURE REGARDING PAYMENTS TO INFLUENCE CERTAIN FEDERAL
TRANSACTIONS
(Applicable to acquisitions over $150,000, when FDIC is acting in its Corporate Capacity)
a. Definitions. As used in this provision “Lobbying contact” has the meaning provided at 2 U.S.C. § 1602(8). The
terms “agency,” “influencing or attempting to influence,” “officer or employee of an agency,” “person,” “reasonable
compensation,” and “regularly employed” are defined in clause 7.3.2-58 entitled “Limitation on Payments to
Influence Certain Federal Transactions.”
b. Prohibition. The prohibition and exceptions contained in clause 7.3.2-58 entitled “Limitation on Payments to
Influence Certain Federal Transactions” are hereby incorporated by reference in this provision.
c. Certification. The offeror, by signing its offer, hereby certifies to the best of its knowledge and belief that no
federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence
an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee
of a Member of Congress on its behalf in connection with the awarding of this contract.
d. Disclosure. If any registrants under the Lobbying Disclosure Act of 1995 have made a lobbying contact on behalf
of the offeror with respect to this contract, the offeror shall complete and submit, with its offer, OMB Standard Form
LLL, Disclosure of Lobbying Activities, to provide the name of the registrants. The offeror need not report regularly
employed officers or employees of the offeror to whom payments of reasonable compensation were made.
e. Penalty. Submission of this certification and disclosure is a prerequisite for making or entering into this contract
imposed by 31 U.S.C. §1352. Any person who makes an expenditure prohibited under this provision or who fails
to file or amend the disclosure required to be filed or amended by this provision, shall be subject to a civil penalty
of not less than $10,000, and not more than $100,000, for each such failure.
6. REPRESENTATION BY CORPORATIONS REGARDING AN UNPAID DELINQUENT FEDERAL TAX
LIABILITY
(Applicable to acquisitions over $100,000)
a. FDIC may not enter into a contract with any corporation that Has any unpaid Federal tax liability that has been assessed, for which all judicial and administrative
remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an
agreement with the authority responsible for collecting the tax liability, where the awarding agency is aware
of the unpaid tax liability, unless the agency has considered suspension or debarment of the corporation
and made a determination that this further action is not necessary to protect the interests of the
Government.
b. The Offeror represents that It is
is not
a corporation that has any unpaid Federal tax liability that has been assessed, for which all
judicial and administrative remedies have been exhausted or have lapsed, and that is not being paid in a
timely manner pursuant to an agreement with the authority responsible for collecting the tax liability.
(Authority: Section 744 of Division E, Title VII, of the Consolidated and Further Continuing Appropriations
Act, 2015 (Pub. L. 113-235)).

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FDIC CONTRACTOR REPRESENTATIONS AND CERTIFICATIONS
7. CERTIFICATION REGARDING FAIR INCLUSION OF MINORITIES AND WOMEN
(Applicable to acquisitions over $100,000)
a. The Contractor certifies to the following:

Yes

No

(1) It is committed to equal opportunity in employment and contracting.
(2) It has made and will continue to make, or will make during the course of this contract, a good faith effort to
ensure, to the maximum extent possible, the fair inclusion of minorities and women in its workforce and in the
workforces of its applicable subcontractors.
(3) For purposes of this certification,
“Minority” shall have the meaning set forth in Section 342 (g) of the Dodd-Frank Wall Street Reform and
Consumer Protection Act, Pub. L. No. 111-203, 124 Stat. 1376 (2010); and “Applicable Subcontractor” refers
to all tiers of subcontractors under this contract whose subcontract exceeds $100,000 in value; and “Good
faith effort,” may include actions by the contractor intended to identify and, if present, remove barriers to
minority and women within its workforce or expand employment opportunities for minorities and women within
its workforce. Efforts to remove such barriers or expand employment opportunities may include, but are not
limited to, recruiting minorities and women, providing job-related training, or other activity that could lead to
those results.
b. If the Contractor answers “No” to paragraph (a) above, an explanation must be provided:

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FDIC CONTRACTOR REPRESENTATIONS AND CERTIFICATIONS
8. COVERED TELECOMMUNICATIONS EQUIPMENT OR SERVICES-REPRESENTATION
(Applicable to all acquisitions)
a. Definitions. As used in this provision, “covered telecommunications equipment or services” and “reasonable
inquiry” have the meaning provided in the clause 7.1.2-2, Prohibition on Contracting for Certain Telecommunications
and Video Surveillance Services or Equipment.
b. Procedures. The Offeror shall review the list of excluded parties in the System for Award Management (SAM)
(https://www.sam.gov) for entities excluded from receiving federal awards for “covered telecommunications
equipment or services”.
c. Representation.
(1) The Offeror represents that it [ ] does, [ ] does not provide covered telecommunications equipment or
services as a part of its offered products or services to the FDIC in the performance of any contract, subcontract,
or other contractual instrument.
(2) After conducting a reasonable inquiry for purposes of this representation, the offeror represents that
it [ ] does, [ ] does not use covered telecommunications equipment or services, or any equipment, system, or
service that uses covered telecommunications equipment or services.

9.

REPRESENTATION REGARDING CERTAIN TELECOMMUNICATIONS AND VIDEO SURVEILLANCE
SERVICES OR EQUIPMENT
(Applicable to all acquisitions)

The Offeror shall not complete the representation at (d)(1) of this provision if the Offeror has represented that it “does not
provide covered telecommunications equipment or services as a part of its offered products or services to the
Government in the performance of any contract, subcontract, or other contractual instrument” in paragraph (c)(1) in the
provision at 7.3.2-76, Covered Telecommunications Equipment or Services-Representation. The Offeror shall not
complete the representation in paragraph (d)(2) of this provision if the Offeror has represented that it "does not use
covered telecommunications equipment or services, or any equipment, system, or service that uses covered
telecommunications equipment or services" in paragraph (c)(2) of the provision at 7.3.2-76.
a. Definitions. As used in this provision -“Backhaul”, “covered telecommunications equipment or services”, “critical technology”, “interconnection
arrangements”, “reasonable inquiry”, “roaming” and “substantial or essential component” have the meanings provided
in clause 7.1.2-2, Prohibition on Contracting for Certain Telecommunications and Video Surveillance Services or
Equipment.
b. Prohibition.
(1) Section 889(a)(1)(A) of the John S. McCain National Defense Authorization Act for Fiscal Year 2019 (Pub. L.
115-232) prohibits the head of an executive agency from procuring or obtaining, or extending or renewing a
contract to procure or obtain, any equipment, system, or service that uses covered telecommunications
equipment or services as a substantial or essential component of any system, or as critical technology as part of
any system. Nothing in the prohibition shall be construed to (i) Prohibit the Chairman of FDIC or designee from procuring with an entity to provide a service that connects
to the facilities of a third-party, such as backhaul, roaming, or interconnection arrangements; or
(ii) Cover telecommunications equipment that cannot route or redirect user data traffic or cannot permit
visibility into any user data or packets that such equipment transmits or otherwise handles.

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FDIC CONTRACTOR REPRESENTATIONS AND CERTIFICATIONS
(2) Section 889(a)(1)(B) of the John S. McCain National Defense Authorization Act for Fiscal Year 2019 (Pub. L.
115-232) prohibits the head of an executive agency from entering into a contract or extending or renewing a
contract with an entity that uses any equipment, system, or service that uses covered telecommunications
equipment or services as a substantial or essential component of any system, or as critical technology as part of
any system. This prohibition applies to the use of covered telecommunications equipment or services, regardless
of whether that use is in performance of work under a Federal contract. Nothing in the prohibition shall be
construed to -(i) Prohibit the Chairman of FDIC or designee from procuring with an entity to provide a service that connects to the
facilities of a third-party, such as backhaul, roaming, or interconnection arrangements; or
(ii) Cover telecommunications equipment that cannot route or redirect user data traffic or cannot permit visibility into
any user data or packets that such equipment transmits or otherwise handles.
c. Procedures. The Offeror shall review the list of excluded parties in the System for Award Management (SAM)
(https://www.sam.gov) for entities excluded from receiving federal awards for “covered telecommunications
equipment or services”.
d. Representation.
(1) The Offeror represents that it [ ] will, [ ] will not provide covered telecommunications equipment or
services to the FDIC in the performance of any contract, subcontract or other contractual instrument resulting
from this solicitation. The Offeror shall provide the additional disclosure information required at paragraph (e)(1)
of this section if the Offeror responds "will" in paragraph (d)(1) of this section; and
(2) After conducting a reasonable inquiry, for purposes of this representation, the Offeror represents that -It [ ] does, [ ] does not use covered telecommunications equipment or services, or use any equipment,
system, or service that uses covered telecommunications equipment or services. The Offeror shall provide the
additional disclosure information required at paragraph (e)(2) of this section if the Offeror responds "does" in
paragraph (d)(2) of this section.
e. Disclosures.
(1) Disclosure for the representation in paragraph (d)(1) of this provision. If the Offeror has responded "will" in the
representation in paragraph (d)(1) of this provision, the Offeror shall provide the following information as part of
the offer:
(i) For covered equipment -(A) The entity that produced the covered telecommunications equipment (include entity name, unique entity
identifier, CAGE code, and whether the entity was the original equipment manufacturer (OEM) or a distributor, if known);
(B) A description of all covered telecommunications equipment offered (include brand; model number, such as
OEM number, manufacturer part number, or wholesaler number; and item description, as applicable); and
(C) Explanation of the proposed use of covered telecommunications equipment and any factors relevant to
determining if such use would be permissible under the prohibition in paragraph (b)(1) of this provision.
(ii) For covered services --

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FDIC CONTRACTOR REPRESENTATIONS AND CERTIFICATIONS
(A) If the service is related to item maintenance: A description of all covered telecommunications services
offered (include on the item being maintained: Brand; model number, such as OEM number, manufacturer part number,
or wholesaler number; and item description, as applicable); or
(B) If not associated with maintenance, the Product Service Code (PSC) of the service being provided; and
explanation of the proposed use of covered telecommunications services and any factors relevant to determining if such
use would be permissible under the prohibition in paragraph (b)(1) of this provision.
(2) Disclosure for the representation in paragraph (d)(2) of this provision. If the Offeror has responded "does" in
the representation in paragraph (d)(2) of this provision, the Offeror shall provide the following information as part
of the offer:
(i) For covered equipment -(A) The entity that produced the covered telecommunications equipment (include entity name, unique entity
identifier, CAGE code, and whether the entity was the OEM or a distributor, if known);
(B) A description of all covered telecommunications equipment offered (include brand; model number, such as
OEM number, manufacturer part number, or wholesaler number; and item description, as applicable); and
(C) Explanation of the proposed use of covered telecommunications equipment and any factors relevant to
determining if such use would be permissible under the prohibition in paragraph (b)(2) of this provision.
(ii) For covered services -(A) If the service is related to item maintenance: A description of all covered telecommunications services
offered (include on the item being maintained: Brand; model number, such as OEM number, manufacturer part number,
or wholesaler number; and item description, as applicable); or
(B) If not associated with maintenance, the PSC of the service being provided; and explanation of the
proposed use of covered telecommunications services and any factors relevant to determining if such use would be
permissible under the prohibition in paragraph (b)(2) of this provision.
10. SMALL BUSINESS REPRESENTATION
(Applicable to all acquisitions. Contracting Officers must enter the NAICS code and small business size
standard prior to providing this form to the offeror(s)).
a. NAICS code and size standard:
(1) The North American Industry Classification System (NAICS) code for this acquisition is:
(2) The small business size standard is:
(3) The small business size standard for a concern which submits an offer in its own name, other than on a
construction or service contract, but which proposes to furnish a product which it did not itself manufacture, is
500 employees.
b. Representation.
This acquisition is not a Small-Business Set-Aside. However, for general statistical purposes, the offeror represents
as part of its quote or offer that it [ ] is, [ ] is not a small business concern.

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FDIC CONTRACTOR REPRESENTATIONS AND CERTIFICATIONS
11. PROHIBITION ON CONTRTACTING WITH ENTITIES THAT REQUIRE CERTAIN INTERNAL CONFIDENTIALITY
AGREEMENTS OR STATEMENTS-REPRESENTATIONS
(Applicable to all acquisitions)
a. Definition. As used in this provisionInternal confidentiality agreement or statement, subcontract, and subcontractor, are defined in the clause at 7.3.2-79,
Prohibition on Requiring Certain Internal Confidentiality Agreements or Statements.
b. In accordance with section 743 of Division E, Title VII, of the Consolidated and Further Continuing Appropriations
Act, 2015 (Pub. L. 113-235) and its successor provisions in subsequent appropriations acts (and as extended in
continuing resolutions), Government agencies are not permitted to use funds to enter into contracts with an entity
that requires employees or subcontractors of such entity seeking to report waste, fraud, or abuse to sign internal
confidentiality agreements or statements prohibiting or otherwise restricting such employees or subcontractors from
lawfully reporting such waste, fraud, or abuse to a designated investigative or law enforcement representative of a
Federal department or agency authorized to receive such information.
c. The prohibition in paragraph (b) of this provision does not contravene requirements applicable to Standard Form
312, (Classified Information Nondisclosure Agreement), Form 4414 (Sensitive Compartmented Information
Nondisclosure Agreement), or any other form governing the nondisclosure of classified information.
d. Representation. By submission of its offer, the Offeror represents that it will not require its employees or
subcontractors to sign or comply with internal confidentiality agreements or statements prohibiting or otherwise
restricting such employees or subcontractors from lawfully reporting waste, fraud, or abuse related to the
performance of a Government contract to a designated investigative or law enforcement representative of a Federal
department or agency authorized to receive such information (e.g., agency Office of the Inspector General).

12. CERTIFICATION REGARDING WHISTLEBLOWER RIGHTS AND REMEDIES
(Applicable to acquisitions over $250,000)
The Contractor certifies to the following:
a. It is committed to protecting whistleblower rights and remedies under 41 U.S.C. § 4712.
b. It has informed and will continue to inform, or will inform during the course of this contract, its employees and any
subcontractor and its employees, in writing, in the predominant language of the workforce, of employee whistleblower
rights and protections under 41 U.S.C. § 4712.

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FDIC CONTRACTOR REPRESENTATIONS AND CERTIFICATIONS
13. SIGNATURE
By signature hereto, the offeror certifies that all of the representations and certifications contained in its
proposal are complete and accurate as required by this solicitation, and that it is aware of the penalty
prescribed in 18 U.S.C. § 1001 for making false statements in proposals. The offeror also agrees to notify
the FDIC in writing, within 10 days, after discovering that it or any person performing services under an
FDIC contract has any of the disqualifying conditions contained within the representations and
certifications. Such notification shall contain a detailed description of the disqualifying condition and may
include a statement of how the offeror intends to resolve such condition. Further, the offeror by signature
hereto gives express authorization and consent to the FDIC for the FDIC to release information contained
herein to licensing authorities in the FDIC's examination of the contractor's compliance with FDIC nonethics contracting regulations.
SOLICITATION NUMBER
NAME OF OFFEROR

UNIQUE ENTITY IDENTIFIER (UEI)

TITLE
NAME OF OFFEROR'S FIRM

OFFEROR'S TELEPHONE NUMBER

OFFICE ADDRESS
CITY
SIGNATURE

FDIC 3700/04A (3-23)

STATE

ZIP CODE
DATE SIGNED

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