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Federal Deposit Insurance Corporation INTERAGENCY BIOGRAPHICAL AND FINANCIAL REPORT

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Page of FDIC 6200/06 (6-18)
OMB No. for FDIC 3064-0006; Expiration Date: June 30, 2021
OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2021
OMB No. for OCC 1557-0014; Expiration Date: February 28, 2021
Federal Deposit Insurance Corporation
INTERAGENCY BIOGRAPHICAL AND FINANCIAL REPORT
Public reporting burden for this collection of information is estimated to average 2.5 hours for biographical information
and 2 hours for financial information. This estimate includes time to gather and maintain data in the required form, to
review instructions, and to complete the information collection. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden to: Paperwork Reduction Act,
Legal Division, Federal Deposit Insurance Corporation (FDIC), 550 17th Street, NW, Washington, DC 20429; Secretary,
Board of Governors of the Federal Reserve System (Board), 20th and C Streets, NW, Washington, DC 20551; or
Licensing Activities Division, Office of the Comptroller of the Currency (OCC), 400 7th St. SW, Washington, DC 20219;
and to the Office of Management and Budget (OMB), Paperwork Reduction Project, Washington, DC 20503.
An organization or a person is not required to respond to a collection of information unless it displays a currently valid
OMB control number.
GENERAL INFORMATION AND INSTRUCTIONS
This Interagency Biographical and Financial Report (report) is used by individuals
1
in conjunction with other
corporate filings to the appropriate federal banking agency. This report is not a standalone document.
Preparation
Use of this report format is not mandatory. If an alternative format is used, it must provide all requested information,
including the certification. All questions must be answered with complete and accurate information that is subject to
verification. If the answer is “none,” “not applicable,” or “unknown,” so state. Answers of “unknown” or “yes” should be
explained.
The questions are not intended to limit the presentation nor are the questions intended to duplicate information supplied
on another form or in an exhibit. For example, a cross-reference to the information is acceptable. Any cross-reference
must be made to a specific cite or location in the documents, so the information can be located easily. Use additional
sheets as necessary. Each appropriate federal banking agency will provide additional instructions for use and
preparation. If the report is not complete, the appropriate federal banking agency may either request additional
information or return the filing. If you are a foreign national or a United States citizen who currently resides in a foreign
country, additional information may be necessary.
Financial statements from individuals must have “as of” dates of not more than 90 days prior to the date the financial
report is submitted. All amounts in this report must be based on current market value in United States dollars
2
and agree
with any totals in the supplementary schedules. In addition to the sample financial schedules, you may wish to provide
supplementary schedules for other items on the financial statement. If the sample financial statement is used, an answer
is required to each item. If you submit an alternative Financial Report format, the information must respond to each
request for information contained in the sample Financial Report.
In addition, each appropriate federal banking agency specifically reserves the right to require up to five years of financial
data from any individual as well as the filing of additional information and/or statements, such as a federal income tax
return or a current appraisal to support an asset's value.
1
A company seeking to acquire direct or indirect control of a bank or savings association should consult with the appropriate federal banking agency for
filing instructions.
2
Provide the foreign currency exchange rate and conversion date, if applicable.
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OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2021
OMB No. for OCC 1557-0014; Expiration Date: February 28, 2021
Preparation (continued)
If you have been convicted of any criminal offense involving dishonesty, breach of trust, or money laundering, or have
agreed to enter into a pretrial diversion or similar program in connection with a prosecution of such offense (12 U.S.C. §
1829), you must obtain approval from the FDIC before you can own, control, participate in the affairs of, or become an
institution-affiliated party of a depository institution.
Each individual must report promptly any material change in the biographical report or financial condition that occurs
during the review period for the filing. For additional information regarding the processing procedures and guidelines,
and any supplemental information that may be required, refer to the appropriate federal banking agency's procedural
guidelines (for example, the OCC's Rules and Regulations (12 C.F.R. Part 5), the Comptroller's Licensing Manual, the
FDIC's Rules and Regulations (12 C.F.R. Part 303), the Board's Regulations Y and LL (12 C.F.R. Part 225 and 12 C.F.R.
Part 238, respectively), and relevant policy statements), contact the appropriate federal banking agency directly for
specific instruction, or visit its website at www.occ.treas.gov, www.fdic.gov, or www.federalreserve.gov.
Definitions
For purposes of this document:
Affiliate means any company that owns or controls, is owned or controlled by, or is under common ownership or control
with a depository institution or depository institution holding company.
Associated means associated as an officer, director, organizer, partner, trustee, or principal shareholder or owner.
Company means any corporation, association, partnership, limited liability company, business trust, sole proprietorship,
joint venture, or other similar organization.
Depository institution means any bank (including a national, state, district, or foreign bank), savings association, savings
bank, savings and loan association, building and loan association, homestead association, cooperative bank, trust
company, industrial bank or loan company, or credit union. A United States office, including a branch or agency, of a
foreign bank is a depository institution.
Management official includes a senior executive officer; director; advisory or honorary director of a depository institution
with total assets of $100 million or more; branch manager; trustee of a depository organization under the control of
trustees; and any person who has a representative or nominee serving in any of those capacities.
Principal shareholder or owner means a person who directly or indirectly owns, controls, or holds (either individually or as
a member of a group) the power to vote 10 percent or more of any class of voting securities or other voting equity interest
of the entity.
Confidentiality
Any individual desiring confidential treatment of specific portions of the report must submit a request in writing with the
report. The request must discuss the justification for the requested treatment. The individual's reasons for requesting
confidentiality should specifically demonstrate the harm (for example, loss of competitive position, invasion of privacy)
that would result from public release of information under the Freedom of Information Act (5 U.S.C. § 552). Information
for which confidential treatment is requested should be: (1) specifically identified in the public portion of the report (by
reference to the confidential section); (2) separately bound; and (3) labeled “Confidential.” The individual should follow
the same procedure for a request for confidential treatment for the subsequent filing of supplemental information to the
report.
The individual should contact the appropriate federal banking agency for specific instructions regarding requests for
confidential treatment. The agency will determine whether the information will be treated as confidential and will advise
the individual of any decision to make available to the public information labeled “Confidential.”
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OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2021
OMB No. for OCC 1557-0014; Expiration Date: February 28, 2021
PRIVACY ACT STATEMENT
Purposes
This form is used by certain shareholders, directors, and executive officers, in conjunction with other filings to the
appropriate banking agency. This Privacy Act statement is made pursuant to the requirements of the Privacy Act of
1974, 5 U.S.C. § 552a.
Authority
The solicitation and collection of this information, including a Social Security Number, is authorized by those statutes that
require an appropriate federal banking agency to determine the competence, experience, integrity, and financial ability of
individuals proposing to serve a federally regulated financial institution in an official capacity. These statutes include: 12
U.S.C. § 27 (national bank charters); 12 U.S.C. § 1464 (federal savings bank charters); 12 U.S.C. § 1815 (federal deposit
insurance); 12 U.S.C. § 1817(j) (changes in control of insured depository institutions); and 12 U.S.C. § 1831(i) (agency
disapproval of directors and senior executive officers of insured depository institutions or depository institution holding
companies).
INFORMATION REGARDING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER UNDER PUBLIC LAW 93-579
SECTION 7(B), IF APPLICABLE
Disclosure by you of your Social Security Number is optional to obtain the services, benefits, or processes that you are
seeking. The Social Security Number provided may be used to conduct a background check on the individual in order to
evaluate the competence, experience, integrity, and financial ability of individuals proposing to serve a federally regulated
financial institution in an official capacity.
Effects of Nondisclosure
Provision of the requested information, including Social Security Number, is voluntary. However, the failure to provide any
requested information may result in the denial, disapproval, or delay in the processing of an application or notice.
Routine Uses for Board Filers
The information you provide will be stored by the Board in the System of Records entitled "BGFRS-37: Electronic
Applications." All or part of the information may be disclosed outside of the Board as follows:
1. To the appropriate federal, state, local, foreign, or self-regulatory organization or agency responsible for
investigating, prosecuting, enforcing, implementing, issuing, or carrying out a statute, rule, regulation, order,
policy, or license if the information may be relevant to a potential violation of civil or criminal law, rule, regulation,
order, policy, or license;
2. To a federal agency in the executive, legislative, or judicial branch of government, or to a Federal Reserve Bank,
in connection with the hiring, retaining, or assigning of an employee, the issuance of a security clearance, the
conducting of a security or suitability investigation of an individual, the classifying of jobs, the letting of a contract,
the issuance of a license, grant, or other benefits by the receiving entity, or the lawful statutory, administrative, or
investigative purpose of the receiving entity to the extent that the information is relevant and necessary to the
receiving entity's decision on the matter;
3. To a congressional office in response to an inquiry made by the congressional office at the request of the
individual to whom the record pertains;
4. To the Department of Justice, a court, an adjudicative body or administrative tribunal, a party in litigation, or a
witness if the Board (or in the case of an Office of Inspector General (OIG) system, the OIG) determines, in its
sole discretion, that the information is relevant and necessary to the matter;
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5. To contractors, agents, or others performing work on a contract, service, cooperative agreement, job, or other
activity for the Board and who have a need to access the information in the performance of their duties or
activities for the Board;
6. To appropriate agencies, entities, and persons when (1) the Board suspects or confirms that the security or
confidentiality of information in the system of records has been compromised; (2) the Board has determined that
as a result of the suspected or confirmed compromise there is a risk of harm to economic or property interest,
identity theft or fraud, or harm to the security or integrity of this system or other systems or programs (whether
maintained by the Board or another agency or entity) that rely upon the compromised information; and (3) the
disclosure is made to such agencies, entities, and persons who are reasonably necessary to assist in connection
with the Board's efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy
such harm; and
7. To other bank and thrift regulatory agencies pursuant to explicit information sharing agreements for regulatory
comment purposes.
Routine Uses for FDIC Filers
The information you provide will be stored by the FDIC in the System of Records entitled "FDIC 30-64-0002: Financial
Institution Investigative and Enforcement Records." All or part of the information may be disclosed outside of the FDIC as
follows:
1. To federal, state, local, foreign, or self-regulatory authorities responsible for investigating or prosecuting a
violation of, or for enforcing or implementing a statute, rule, regulation, or order issued, when the information
indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and whether
arising by general statute or particular program statute, or by regulation, rule, or order issued pursuant thereto;
2. To a court, magistrate, or other administrative body in the course of presenting evidence, including disclosures to
counsel or witnesses in the course of civil discovery, litigation, or settlement negotiations or in connection with
criminal proceedings, when the FDIC is a party to the proceeding or has a significant interest in the proceeding,
to the extent that the information is determined to be relevant and necessary;
3. To a congressional office in response to an inquiry made by the congressional office at the request of the
individual who is the subject of the record;
4. To appropriate agencies, entities, and persons when (1) FDIC suspects or has confirmed that there has been a
breach of the system of records; (2) FDIC has determined that as a result of the suspected or confirmed breach
there is a risk of harm to individuals, FDIC (including its information systems, programs, and operations), the
federal government, or national security; and (3) the disclosure made to such agencies, entities, and persons is
reasonably necessary to assist in connection with FDIC's efforts to respond to the suspected or confirmed breach
or to prevent, minimize, or remedy such harm;
5. To another federal agency or federal entity, when FDIC determines that information from this system of records is
reasonably necessary to assist the recipient agency or entity in (1) responding to a suspected or confirmed
breach or (2) preventing, minimizing, or remedying the risk of harm to individuals, the recipient agency or entity
(including its information systems, programs, and operations), the federal government, or national security,
resulting from a suspected or confirmed breach;
6. To federal, state, or foreign authorities in connection with hiring or retaining an individual, conducting a
background security or suitability investigation, adjudication of liability, or eligibility for a license, contract, grant,
or other benefit;
7. To contractors, grantees, volunteers, and others performing or working on a contract, service, grant, cooperative
agreement, or project for the FDIC, the OIG, or the federal government for use in carrying out their obligations
under such contract, grant, agreement or project;
8. To federal, state or foreign financial institutions supervisory authorities for regulatory or enforcement purposes;
and
9. To a financial institution affected by enforcement activities or reported criminal activities.
PRIVACY ACT STATEMENT
(continued)
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OMB No. for FDIC 3064-0006; Expiration Date: June 30, 2021
OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2021
OMB No. for OCC 1557-0014; Expiration Date: February 28, 2021
Routine Uses for OCC Filers
The information you provide on this form, if the form is submitted in connection with a notice of proposed change in
employee, officer or director, may be stored by the OCC in the System of Records entitled "Notice of Proposed Changes
in Employees, Officers and Directors Tracking System." Information maintained in this system may be disclosed to:
1. A Section 5.51 entity, a Section 5.20(g)(2) entity, a part 163, subpart H entity, or a Section 1818(b) entity in
connection with review and action on a notice filed by that entity;
2. Third parties to the extent necessary to obtain information that is pertinent to the OCC's review and action on a
notice received under any authority cited herein;
3. Appropriate governmental or self-regulatory organizations when the OCC determines that the records are
relevant and necessary to the governmental or self-regulatory organization's regulation or supervision of financial
service providers, including the review of the qualifications and fitness of individuals who are or propose to
become responsible for the business operations of such providers;
4. An appropriate governmental, tribal, self-regulatory, or professional organization if the information is relevant to a
known or suspected violation of a law or licensing standard within that organization's jurisdiction;
5. The Department of Justice, a court, an adjudicative body, a party in litigation, or a witness if the OCC determines
that the information is relevant and necessary to a proceeding in which the OCC, any OCC employee in his or
her official capacity, any OCC employee in his or her individual capacity represented by the Department of
Justice or the OCC, or the United States is a party or has an interest;
6. A congressional office when the information is relevant to an inquiry made at the request of the individual about
whom the record is maintained;
7. A contractor or agent who needs to have access to this system of records to perform an assigned activity;
8. Third parties when mandated or authorized by statute; or
9. Appropriate agencies, entities, and persons when: (a) The Department suspects or has confirmed that the
security or confidentiality of information in the system of records has been compromised; (b) the Department has
determined that as a result of the suspected or confirmed compromise there is a risk of harm to economic or
property interests, identity theft or fraud; or harm to the security or integrity of this system or other systems or
programs (whether maintained by the Department or another agency or entity) that rely upon the compromised
information; and (c) the disclosure made to such agencies, entities, and persons is reasonably necessary to
assist in connection with the Department's efforts to respond to the suspected or confirmed compromise and pre-
vent, minimize, or remedy such harm.
PRIVACY ACT STATEMENT
(continued)
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OMB No. for OCC 1557-0014; Expiration Date: February 28, 2021
Federal Deposit Insurance Corporation
INTERAGENCY BIOGRAPHICAL AND FINANCIAL REPORT
This is filed with respect to:
Name of Subject Institution or Holding Company
City, State
Type of Filing (Check all that apply):
Bank or Savings Association Charter
Bank or Savings and Loan Holding Company
Change in Bank Control
Change in Senior Executive Officer or Director
Citizen Waiver
Charter Conversion
Deposit Insurance
Federal Branch or Agency
Other
Position (Check all that apply):
Other
Manager
Trustee
Principal Shareholder
Senior Executive Officer
Director
Organizer
BIOGRAPHICAL REPORT
1. Personal Information
a. Name
Last First Middle (Full Name)
b. Residence
Street Address
City/Town State/Province ZIP/Postal Code Country
c. If at a residence less than five years, list addresses and dates occupied for past five years.
Date From Date To Number and Street City State/Province ZIP/Postal Code Country
d. Date of Birth
Month / Day / Year
Reset Form
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e. Place of Birth
City
State/Province
Country
f. United States Social Security Number
g. Are you a United States citizen?
Yes No
Date, if naturalized:
h. If not a United States citizen, or if you have dual citizenship, provide:
County of Citizenship
Passport Number / Expiration Date
Home Country Identification Number
Immigration File Number
Father's Full Name
Mother's Full Name, including maiden name
Telephone Number(s) where you can be reached during business hours
Email Address
i. List other names you used and the period of time you used them (for example, your maiden name, name by a
former marriage, former name, alias, or nickname). If the other name is your maiden name, put “nee” in front of it.
Period of Time Used
Other Names Used Beginning Date Ending Date
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OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2021
OMB No. for OCC 1557-0014; Expiration Date: February 28, 2021
2. Employment Record
a. List employment in reverse chronological order for the last five years. Provide the following information. (If the
applicant has additional relevant employment experience, or additional information to support the application,
provide an attachment.)
Beginning Date
Ending Date
Employer's Name
City
State/Province
Nature of Business Title or Position Nature of Duties
Reason for Leaving
b. Have you ever been dismissed or asked to resign from any past employment, including a less than honorable
discharge from military service?
Yes No If Yes, provide the following information:
Employer's Name Street City State/Province Area Code/Phone Number
Title or Position Date of Discharge
Explanation
Street
Reason for Leaving
Nature of Duties
Title or Position
Nature of Business
State/Province
City
StreetEmployer's Name
Ending Date
Beginning Date
Reason for Leaving
Nature of DutiesTitle or Position
Nature of Business
State/Province
City
Street
Employer's Name
Ending Date
Beginning Date
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OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2021
OMB No. for OCC 1557-0014; Expiration Date: February 28, 2021
3. Education and Professional Credentials
a. List each diploma or degree from high schools, colleges, universities, or other schools.
School's Name Address Date From Date To Degree
b. List each professional license or similar certificate you now hold or have held (for example: Attorney, Physician,
CPA, NASD, or SEC registration)
License Issuing Authority Date Issued Status Expiration
4. Business and Banking Affiliations
a. List any company with which you are Associated and provide the following information:
Company Name Address Nature or Type of Business
Ownership Percentage Start DatePosition Held or Relationship to the Company
Position Held or Relationship to the Company Start DateOwnership Percentage
Nature or Type of BusinessAddressCompany Name
Start DateOwnership PercentagePosition Held or Relationship to the Company
Nature or Type of BusinessAddressCompany Name
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b. List the name of any depository institution or depository institution holding company with which you are or were
Associated and provide the following information:
Depository Institution/Holding Company Name
Address
Nature of Banking Activity
Start DateOwnership PercentagePosition Held or Relationship to the Company End Date
End DateStart Date
Nature of Banking Activity
Ownership Percentage
Address
Position Held or Relationship to the Company
Depository Institution/Holding Company Name
End DateStart Date
Nature of Banking Activity
Ownership Percentage
Address
Position Held or Relationship to the Company
Depository Institution/Holding Company Name
End DateStart Date
Nature of Banking Activity
Ownership Percentage
Address
Position Held or Relationship to the Company
Depository Institution/Holding Company Name
If Yes, provide the name of the depository institution or depository institution holding company
and the position. If the application has been submitted for regulatory review, provide the name
of the appropriate Federal banking agency.
Yes
No
c. Are you in the process of being considered for a Management official position at another depository
institution or depository institution holding company?
Depository Institution/Holding Company Name
Position
Appropriate Federal Banking Agency
Yes
No
If “yes,” explain either why the potential interlock is not a violation of the Depository Institution
Management Interlocks Act (12 U.S.C. §§ 3201-3208) or what action will be taken to prevent a
violation.
d. Are you now or are you proposed to be a Management official of another insured depository institution or
depository institution holding company?
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5. Legal and Related Matters (If you answer Yes to any question, see question 5g)
a. Have you been involved in any of the following filings where the filing was denied, disapproved, withdrawn, or
otherwise returned without favorable action by a federal or state regulatory authority or a self-regulatory
organization:
1. A charter or license application, a depository institution holding company application, or a federal deposit
insurance application, in which you were listed as an organizer, director, senior executive officer, or a person
that would own or control (either individually or as a member of a group) 10 percent or more of any class of
voting securities or other voting equity interest of the institution, or similar position?
2. A merger application in which you were listed as a director, senior executive officer, or similar position?
3. A notice of change in director or senior executive officer, or similar form, in which you were listed as a
director, senior executive officer, or similar position?
4. A notice of change in control for a depository institution or other company, or a similar form, in which you were
listed (either individually or as a member of a group) as an acquirer or transferee?
5. Any other application, notice, or other regulatory or administrative request which was filed with a federal or state
regulatory authority or a self-regulatory organization in which you were listed in some capacity?
b. Have you or any depository institution or depository institution holding company with which you are or were
Associated been subject to any supervisory agreement, enforcement action, civil money penalty, prohibition or
removal order, or other supervisory or administrative action taken or imposed by any federal or state regulatory
authority or other governmental entity?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
c. Has any depository institution with which you are or were Associated:
Yes No
1. Been placed into conservatorship or receivership or otherwise failed?
Yes No
2. Received financial assistance from a federal agency or instrumentality (for example: FDIC, Resolution Trust
Corporation, Federal Savings and Loan Insurance Corporation)?
Yes No
3. Merged with or been acquired by an institution that received financial assistance from a federal agency or
instrumentality in connection with the transaction?
Yes No
1. Filed a petition under any chapter of the Bankruptcy Code or had an involuntary bankruptcy petition filed
against you or the company?
d. Have you or any company with which you are or were Associated:
2. Defaulted on a loan or financial obligation of any sort, whether as obligor, cosigner, or guarantor?
Yes No
3. Forfeited property in full or partial satisfaction of any financial obligation?
NoYes
4. Had a lien placed against property for failure to pay taxes or other debts?
Yes No
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Yes No
5. Had wages or income garnished for any reason?
Yes No
6. Failed or refused to pay any outstanding judgments?
Yes No
7. Failed to satisfy any federal, state, or local tax obligations?
e. Have you or any company or depository institution with which you are or were Associated been involved in any
criminal or civil lawsuit, formal or informal investigation, examination, or administrative proceeding that may
result in, or resulted in, any penalty (including, but not limited to, any sanction, fine, order to pay damages, loss of
right or benefit, forfeiture of property interest, suspension, removal, disbarment, or revocation of license),
agreement (including a deferred prosecution agreement, consent order, written agreement or memorandum of
understanding), undertaking, consent, judgment, or order imposed by or entered into with any of the following
entities:
Yes No
1. Any state, federal, or foreign court?
Yes No
2. Any department, agency, or commission of the United States government?
Yes No
3. Any state, municipal, or foreign governmental entity?
Yes No
4. Any self-regulatory organization (for example: NASD, FASB, state bar)?
Yes No
f. Have you or any company or depository institution with which you are or were Associated ever been arrested for,
charged with, indicted for, convicted of, or pleaded nolo contendere to, any criminal matter (including, but not
limited to, driving under the influence, reckless driving and disorderly conduct)?
g. If you answer Yes to any question in 5(a) through 5(f), provide your explanation by identifying the number of the
question, describing the situation in detail (providing supplemental documentation as appropriate), and, where
relevant, including the:
■ Date of any relevant event;
■ Name of any regulatory agency or self-regulatory organization involved;
■ Name and location of any institution, company or party involved;
■ Nature of your association with any institution or company (for example: officer, director, organizer, principal
shareholder, or owner);
■ Type of any application, notice, or other regulatory or administrative request;
■ Nature of any supervisory, enforcement, or administrative action;
■ Direct and indirect debt terms, defaulted amount, and creditor regarding any financial obligation;
■ Nature of any lawsuit, charge, proceeding, conviction, or finding;
■ Jurisdiction and court in which any legal proceeding occurred; and
■ Resolution or disposition of the matter.
For any of the matters noted above, indicate whether any insured depository institution suffered a loss as a
result. If so, identify the insured depository institution and the amount of the loss, and indicate whether the
institution was ever made whole.
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6. Additional Information
Present any other information you believe is important to evaluate your filing. If you are involved in the organization
of a new depository institution or depository institution holding company, discuss your specific role.
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OMB No. for FDIC 3064-0006; Expiration Date: June 30, 2021
OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2021
OMB No. for OCC 1557-0014; Expiration Date: February 28, 2021
FINANCIAL REPORT
ASSETS LIABILITIES AND NET WORTH
Cash on hand and in
depository institutions
$ Accounts payable $
Marketable securities
(Schedule A)
Notes payable and other loans
(Schedule F)
Notes receivable
(Schedule B)
Real estate mortgages
(Schedule C)
Real estate (Schedule C,
current market value)
Other liabilities (Schedule G)
Proprietary interests and other
securities (Schedule D)
TOTAL LIABILITIES
Retirement funds and other
assets (Schedule E)
Net worth (Total assets less
total liabilities)
TOTAL ASSETS $
TOTAL LIABILITIES
AND NET WORTH
$
*For any debt reported on any of the supporting schedules, indicate any liability that is contractually delinquent
and provide a discussion on how the delinquency will be resolved.
Financial Statement as of
Month/Year
Page of FDIC 6200/06 (6-18)
OMB No. for FDIC 3064-0006; Expiration Date: June 30, 2021
OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2021
OMB No. for OCC 1557-0014; Expiration Date: February 28, 2021
CONTINGENT LIABILITIES
In addition to the liabilities listed on the Financial Statement, have you endorsed, guaranteed, or become otherwise
indirectly or contingently liable for the debts of others or through a pending lawsuit?
Yes No
If Yes, complete the following:
Debtor or Obligor Due Date
Current
Amount
Description and Value of
Collateral
Creditor or Obligee
Name
$
Name
Address Address
Name Name
Address Address
Name Name
Address Address
Name Name
Address
Address
Name Name
Address Address
Total: $
Page of FDIC 6200/06 (6-18)
OMB No. for FDIC 3064-0006; Expiration Date: June 30, 2021
OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2021
OMB No. for OCC 1557-0014; Expiration Date: February 28, 2021
SUPPORTING SCHEDULES
Schedules must agree in total with the appropriate item contained in the Financial Statement on page 14 of this
report.
Schedule A ─ Marketable Securities
Indicate all debt and equity securities listed on an exchange or otherwise regularly traded in an open market. Separate
debt and equity securities. Securities of closely held corporations should be listed on Schedule D - Proprietary Interests.
The description should include the name of the issuer, the principal amount or number of shares held, and the interest
rate, if applicable. Small holdings may be aggregated and shown as “other” provided that they account for no more than
10 percent of marketable securities.
Description Market Value
$
Total $
Schedule B ─ Notes Receivable
The description should include the name of the obligor, the note's maturity and terms of repayment, and a description of
any collateral. If the note is payable to you and others jointly, indicate only your beneficial interest under Current
Balance.
Description Current Balance
$
Total $
Page of FDIC 6200/06 (6-18)
OMB No. for FDIC 3064-0006; Expiration Date: June 30, 2021
OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2021
OMB No. for OCC 1557-0014; Expiration Date: February 28, 2021
Schedule C ─ Real Estate and Related Loans
List all real estate in which you hold a beneficial interest. Submit year-end financial statements, including profit and loss
statements, for the last two years for each investment (exclude residence) in which you have an interest equal to 10
percent or more of your net worth. Also submit a cash flow statement on any investment property valued at 10 percent or
more of net worth.
Description and
Address of Property
Owner of
Property
Percent
Ownership
Mortgage
Holder
Maturity
Date
Current
Mortgage
Balance
1
Current
Market Value
2
% $ $
%
%
%
%
TOTAL
$ $
1
Carry total forward to Liabilities, Real estate mortgages
2
Carry total forward to Assets, Real estate
Schedule D ─ Proprietary Interests and Other Securities
List all companies, the shares of which are not listed on a securities exchange or otherwise regularly traded, in which you
hold a beneficial interest. (Submit year-end financial statements, including profit and loss and cash flow statements, for
the last two years for each business interest in which you have an interest equal to 10 percent or more of your net worth.)
Name and
Address of Company
Legal Form
of Company
Nature of Business
Percent
Ownership
Current Value
% $
%
%
%
%
TOTAL $
Page of FDIC 6200/06 (6-18)
OMB No. for FDIC 3064-0006; Expiration Date: June 30, 2021
OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2021
OMB No. for OCC 1557-0014; Expiration Date: February 28, 2021
Schedule E - Other Assets
Include retirement funds (for example, 401K, IRA, Keogh), accounts receivable, merchandise and inventory at lower of
cost or market value, machinery and equipment (less depreciation), and life insurance at its cash surrender value.
Description Basis for Valuation Current Value
$
TOTAL $
Schedule F ─ Notes Payable and Other Loans
Indicate all loans or notes payable, including loans on life insurance and retirement funds (but not real estate mortgages
listed in Schedule C). Loan origination information must include the original date, loan amount, and co-makers, if any,
and their percent obligation. Small obligations may be aggregated and shown as “other,” provided that they account for
no more than 20 percent of other loans and notes payable. Indicate any debt that is contractually delinquent by an
asterisk next to the current balance.
Name and Address of Creditor
and Loan Origination Information
Description and
Value of Collateral
Maturity
Date
Current
Balance
$
TOTAL $
Page of FDIC 6200/06 (6-18)
OMB No. for FDIC 3064-0006; Expiration Date: June 30, 2021
OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2021
OMB No. for OCC 1557-0014; Expiration Date: February 28, 2021
Schedule G - Other Liabilities
Include interest and taxes due and unpaid, other debts accrued, and other liabilities.
Payable To Description
Maturity
Date
Current Balance
$
TOTAL $
Page of FDIC 6200/06 (6-18)
OMB No. for FDIC 3064-0006; Expiration Date: June 30, 2021
OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2021
OMB No. for OCC 1557-0014; Expiration Date: February 28, 2021
CASH FLOW STATEMENT
1
Sources of Cash Year Year
Projected
Current Year
Projected
Next Year
Salaries, wages, commissions,
and other employment income
Rents, royalties, and investments
Income from dividends and
interest
Income and other distributions
from partnerships
Other sources
2
Total cash received
Uses of Cash
Personal living expenses (rent,
household)
Fixed obligations
3
Income taxes
Capital contributions to
partnerships
Other uses
2
Total cash outlay
Net Cash Flow (deficit)
1
Discuss any significant changes from one year to the next on a separate page.
2
Itemize on a separate page any items amounting to 10 percent or more of total cash received or total cash outlay.
3
Fixed obligations include debt service on all loans and any budgeted capital improvement expenditures for real estate
investments. Any loan proceeds or debt service related to this transaction should be included in projections for other
sources or uses.
Page of FDIC 6200/06 (6-18)
OMB No. for FDIC 3064-0006; Expiration Date: June 30, 2021
OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2021
OMB No. for OCC 1557-0014; Expiration Date: February 28, 2021
CERTIFICATIONS
Biographical and Financial Report Certification (Individual Applicant)
I understand that the appropriate federal banking agency may conduct extensive checks into my background, experience,
and related matters in conjunction with my application or filing. I certify that the information contained in the biographical
report and financial report, including all attachments, has been carefully examined by me and is true, correct, and
complete. I acknowledge that any misrepresentation or omission of a material fact constitutes fraud in the inducement
and may subject me to legal sanctions provided by 18 U.S.C. §§ 1001 and 1007.
Signed this
Day
day of
Month
,
Year
Signature
Print or Type Name
Title (if applicable)
Signature
Print or Type Name
Title (if applicable)
Financial Report Certification (If filing joint financial statements, Individual Applicant's spouse must complete
the following certification.)
I understand that the appropriate federal banking agency may conduct extensive checks in conjunction with the
information contained in the joint financial report. I certify that the information contained in the joint financial report,
including all attachments, has been carefully examined by me and is true, correct, and complete. I acknowledge that any
misrepresentation or omission of a material fact constitutes fraud in the inducement and may subject me to legal
sanctions provided by 18 U.S.C. §§ 1001 and 1007.
Signed this
Day
day of
Month
,
Year
Signature
Print or Type Name
Title (if applicable)
Title (if applicable)
Print or Type Name
Signature
.
.
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Federal Deposit Insurance Corporation INTERAGENCY BIOGRAPHICAL AND FINANCIAL REPORT

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Completed 27 April 2020

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