Privacy Act Statement: In accordance with the Privacy Act (5 U.S.C. 552a), the following notice is provided. This information is solicited
un
der 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 you not meeting the statutory and regulatory eligibility requirements to serve as a member
director. The purpose of this information is to facilitate the timely determination of your eligibility to serve as a member 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 https://www.fhfa.gov/SupervisionRegulation/Rules/Pages/Privacy-Act-of-1974-System-of-Records-Notice-
of-the-Establishment-of-New-Systems-of-Records.aspx.
Page 4 of 4 Expires 2/28/2021
OMB No. 2590-0006
FEDERAL HOME LOAN BANK MEMBER DIRECTOR ELIGIBILITY CERTIFICATION FORM: DIRECTIONS
Line-by-Line Instructions
LINE 1. Print or type your full name.
LINE 2. You must be a United States citizen in order to serve as a member director. Check the
appropriate answer.
LINE 3. Provide the address of your principal residence.
LINE 4. You must be an officer or a director of an institution that is a member of the Bank in
order to be a member director of that Bank. In addition, the member must be located in the state
within the Bank district that is to be represented by the directorship you wish to hold. In most
cases, a member will be deemed to be located where it maintains its home office or its principal
place of business. Provide the requested information for the member you serve as an officer or
director, as well as your title or position at that institution.
LINE 5. If you are an officer or director of any other institution that is a member of this or any
other Bank, provide the name and location of the institution(s), as well as the position that you
hold at the institution(s).
LINE 6. In order for you to be eligible to serve as a member director, every institution that
you serve as an officer or director that is a member of the Bank in which you wish to hold a
directorship must be in compliance with all of its applicable minimum capital requirements
established by its appropriate federal or state regulator. The term “appropriate federal
regulator” has the same meaning as the term “appropriate Federal banking agency” in
section 3(q) of the Federal Deposit Insurance Act (12 U.S.C. § 1813(q)) and, for federally
insured credit unions, means the National Credit Union Administration. The term
“appropriate state regulator” means any state officer, agency, supervisor, or other entity that
has regulatory authority over, or is empowered to institute enforcement action against, a
member.
Check the appropriate answer as to whether each institution you listed in LINE 4 and
LINE 5 is in compliance with all of the applicable minimum capital requirements
established by its appropriate federal or state regulator. If the answer is No, you must list
each non-compliant institution regardless of the Bank of which it is a member. However,
your status as an officer or director of a non-compliant institution will render you ineligible
to serve as a Bank director only if that institution is a member of the Bank in which you
wish to hold a directorship.
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.
