Independent Direct FHFA Form 130 - Federal Home Loan Bank Independent Direc

FEDERAL HOUSING FINANCE AGENCY
Federal Home Loan Bank Independent Director
Annual Certification Form
INSTRUCTIONS

FHFA Form #130
(03/2023)

Clear Form

The Federal Home Loan Bank of
(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

.

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, 12
U.S.C. 1427(a) and (b), and in Federal Housing Finance Agency regulations at 12 CFR 1261.5(c) and 1261.10.
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PERSONAL INFORMATION
Please provide your personal information as indicated in Questions 1 – 4.

1. Full Name:
2. Other Names Used or Known by:
3. Contact Information:
Phone Number:
Home:

Office:

Cell:

Email Address:
Mailing Address:

Number/Street (or PO Box)

City

State

ZIP Code

City

State

ZIP Code

4. Current Employment, if applicable:
Current Employer:
Your Title:
Your Employment Address:

Number/Street (or PO Box)

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. Please provide the street address of your principal residence.
Address:

Number/Street

City

State

ZIP Code

If the residence entered in response to Question 6A is located within the Bank District, you meet the residency
requirement and may skip to Question 7.
If your principal residence is not located within the Bank District, you may still meet the residency requirement
if you own or lease another residence located within the Bank District and are employed within the Bank
District; in this case, please continue with Question 6B. If you do not own or lease any residence within the
Bank District, you are ineligible to be nominated for an independent directorship.

B. If your principal residence is not located within the Bank District, but you own or lease another
residence within the Bank District, please provide the address of that residence.
Address:

Number/Street

City

C. Are you employed within the Bank District?

State

Yes

ZIP Code

No

D. If you answered Yes to Question 6C, please identify your in-District employer:
Check if your in-District employment information is the same as that entered in response to
Question 4.
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:
Your Employment Address:

Number/Street

State

City

ZIP Code

Independence
The information you provide below will enable the Bank to determine whether you continue to meet the
independence requirements. You may be nominated if you do not currently meet the independence requirements,
but you must agree as part of the certification at the end of this Form that you and your spouse will relinquish any
positions that the Bank determines to be prohibited under those requirements. If elected, you may not be seated
as an independent director so long as you or your spouse hold any such prohibited positions and, once seated,
would become ineligible to continue to serve as an independent director if you or your spouse were to take any
such prohibited positions.
7. Employment by a Federal Home Loan Bank.
A. Are you or your spouse an officer or employee of any Federal
Home Loan Bank?

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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:
Name of the Person Holding the Position:
Federal Home Loan Bank of:
Title:
Date Position Began (MM/YYYY):
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:
Name of the Person Holding the Position:
Name of the Employer:
Choose 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
Title:
Date Position Began (MM/YYYY):
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.

Note if more space needed for answer to Question 8, continue typing response onto page 5.
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Continuation of Answer to Question 8

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/Date:

Reminder: Apply your electronic signature above here. If you physically sign, please include date.

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 FHFA-8 Federal Home Loan Bank Directors, which
may be found at here.

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 07/31/2024
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