Form NCUA 3250 NCUA 3250 Application to Request Consent Pursuant to Section 205(d

OMB No. 3133-0203

NATIONAL CREDIT UNION ADMINISTRATION
APPLICATION TO REQUEST CONSENT PURSUANT TO SECTION 205(d)
The estimated average public reporting burden associated with this information collection is 2 hours per response. Comments
concerning the accuracy of this burden estimate and or any other aspect of this information collection, including suggestions for
reducing this burden should be address to the National Credit Union Administration, ATTN: NCUA PRA Clearance Officer,
1775 Duke Street, Alexandria, Virginia 22314. An agency may not conduct or sponsor, and a person is not required to respond
to, an information collection unless it displays a valid OMB control number.

Section 205(d)(1) of the Federal Credit Union Act, 12 U.S.C. §1785(d)(1), provides that, except with the
prior written consent of the National Credit Union Administration Board (Board), a person who has been
convicted of any criminal offense involving dishonesty or breach of trust, or has agreed to enter into a
pretrial diversion or similar program in connection with a prosecution for such offense may not become,
or continue as an institution-affiliated party with respect to any insured credit union; or otherwise
participate, directly or indirectly, in the conduct of the affairs of any insured credit union.
Section 205(d)(1)(B) further provides that an insured credit union may not allow any person described
above to engage in any conduct or to continue any relationship prohibited by Section 205(d). Section
205(d)(3) states that “whoever knowingly violates” (d)(1)(A) or (d)(1)(B) is committing a felony,
punishable by up to five years in jail and a fine of up to $1,000,000 a day. The statute also prescribes a
minimum ten-year prohibition period for certain offenses.
The Board issued Interpretive Ruling and Policy Statement (IRPS) 19-1, entitled Exceptions to
Employment Restrictions under Section 205(d) of the Federal Credit Union Act (“Second Chance
IRPS”), to assist credit unions and individuals in requesting the Board’s consent pursuant to Section
205(d). IPRS 19-1 is available on the NCUA’s website at https://www.ncua.gov/regulationsupervision/rules-regulations/interpretive-rulings-policy-statements, by contacting the Office of General
Counsel at 703-518-6540 or OGCmail@ncua.gov or from any NCUA Regional Office.
All requests for the Board’s consent pursuant to Section 205(d) should be submitted using the attached
form. Please consult IRPS 19-1 prior to completing the attached application, as not all criminal
convictions require an application to be submitted. IRPS 19-1 also lists the factors the Board will
consider when evaluating any application for consent.
Any questions regarding the process to request the Board’s consent pursuant to Section 205(d), including
whether an application is required, may be directed to the Office of General Counsel at 703-518-6540 or
OGCmail@ncua.gov.
Completed application should be sent to the appropriate NCUA Regional Office or other program office.

NCUA Form 3250 (REV 11/19)

OMB No. 3133-0203

NATIONAL CREDIT UNION ADMINISTRATION
APPLICATION TO REQUEST CONSENT PURSUANT TO SECTION 205(d)
SECTION A – APPLICANT INFORMATION
1. Applicant:

Credit union-sponsored

Individual

Generally, an application must be filed by an insured credit union on behalf of a person. If the applicant is an individual, please explain why
there is substantial good cause for the NCUA Board to grant a waiver of the institution filing requirement.

2. Applicant Name:

3. Date of Application:
4. Address of Applicant (Street, City, County, State, and Zip Code):

I/We have, in connection with preparing this Application, read Section 205(d)(1) & (3) of the Federal Credit Union Act, 12 U.S.C. §1785(d)(1) &
(3), which governs requests by insured credit unions for the consent of the National Credit Union Administration Board for a person who has
been convicted of a crime involving dishonesty or breach of trust, or who has agreed to enter into a pretrial diversion or similar program in
connection with a prosecution for such offense, to become or continue as an institution-affiliated party, or otherwise participate, directly or
indirectly, in the conduct of the affairs of an insured credit union.
In support of this Application, the following statements, representations and information are submitted for the purpose of inducing the National
Credit Union Administration Board to grant its written consent to the person identified below (the prohibited person), who has been convicted of
a crime involving dishonesty or breach of trust or has agreed to enter into a pretrial diversion or similar program in connection with a prosecution
for such offense, to become or continue as an institution-affiliated party, or otherwise participate, directly or indirectly, in the conduct of the
affairs of this credit union. NOTE: the Biographical Information Concerning the Prohibited Person (Section B) and Information Relative to the
Prohibited Person’s Convictions (Section C) should be completed by the prohibited person.

SECTION B – BIOGRAPHICAL INFORMATION CONCERNING THE PROHIBITED PERSON
1. Name of Prohibited Person:

2. Address of Prohibited Person (Street, City, County, State, and Zip Code):

3. Date of Birth (Month, Day, Year):
4. Place of Birth (City, State, and Country):
5. Social Security Number (See Privacy Act Statement on page 4):
6. Name and Address of Present of Most Recent Employer (Street, City, County, State, and Zip Code):

NCUA Form 3250 (Rev. 11/19)

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SECTION C – INFORMATION RELATIVE TO THE PROHIBITED PERSON’S CONVICTIONS
1. Description or Nature of Crime:

a. Date of Conviction:

b. Name and Address of Court:

c. Disposition of the Charges:

NOTE: Additional conviction(s) or program entry or entries for a crime involving dishonesty or breach of trust discovered subsequent to
approval of this Application will require the submission of another application.
2. Briefly describe the nature of the offense and the circumstances surrounding it. Include age of the prohibited person at the time of
conviction, date of the offense, and any mitigating circumstances (parole, suspension of sentence, pardon, etc.). Attach additional pages if
necessary.

3. Briefly describe the extent of rehabilitation the prohibited person completed (attach supporting documents, if any).

4. Attach documentation of the Indictment, Information, or Complaint and Final Decree of Judgment, if available (Normally these can be
obtained from the clerk of court of the relevant jurisdiction. If not provided, explain reasons for unavailability).

5. List any other pertinent facts relative to the crime which are not disclosed in the indictment or other court documents. Attach additional
pages if necessary.

NCUA Form 3250 (Rev. 11/19)

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I do hereby certify that the Biographical Information Concerning the Prohibited Person (Section B) and Information Relative to the Prohibited
Person’s Convictions (Section C) are true and correct to the best of my knowledge and belief.

______________________________________________________
SIGNATURE OF THE PROHIBITED PERSON

__________________
DATE SIGNED

PRIVACY ACT NOTICE
Authority: 12 U.S.C. § 1785(d) (“Section 205(d)”)
Purpose: The NCUA will use the information provided on this form to evaluate your application for the NCUA Board’s consent to allow you to
become or continue as an institution-affiliated party, or otherwise participate, directly or indirectly, in the conduct of the affairs of an insured
credit union.
Routine Uses: This form may be disclosed to render legal advice, as part of judicial or administrative proceedings, to appropriate Federal or State
credit union regulatory agencies and law enforcement or other governmental agencies if relevant to processing or necessary for administrative
reasons or otherwise. A complete list of Routine Uses is available at www.ncua.gov/privacy.
Effects of Not Providing Information: Failure to complete this form or omission of any item of information, except for disclosure of your social
security number, may result in a delay in the processing of this application. In accordance with Section 792.68 of NCUA’s regulations, you are
not required to furnish your social security number on this form. Your social security number, if voluntarily provided, will be used to more easily
verify the information required by this form.
SORN: NCUA-13, Litigation Case Files, 75 FR 41539

NCUA Form 3250 (Rev. 11/19)

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