Fill - Free fillable Form 6710 07 (Federal Deposit Insurance Corporation) PDF form

OMB No.: 3064-0018

Expiration Date: 10/31/2021

FEDERAL DEPOSIT INSURANCE CORPORATION

APPLICATION PURSUANT TO SECTION 19

OF THE FEDERAL DEPOSIT INSURANCE ACT

FDIC 6710/07 (10-18)

Pursuant to Section 19 of the Federal Deposit Insurance Act, 12 U.S.C. § 1829(a), persons convicted of certain

criminal offenses are prohibited from participating in the affairs of an insured depository institution without the express

written consent of the FDIC. This prohibition applies to any person convicted of a criminal offense involving

dishonesty, breach of trust, or money laundering or who has entered into a pretrial diversion or similar program in

connection with a prosecution for such offense. In the absence of prior FDIC approval, such persons are prohibited

from being directly or indirectly affiliated with an insured depository institution, owning or controlling an insured

depository institution, or otherwise directly or indirectly participating in the conduct of the affairs of an insured

depository institution. Insured depository institutions are also prohibited from permitting such persons from engaging

in any of the aforementioned activities.

PRIVACY ACT STATEMENT

The FDIC is authorized to request this information from you by 12 U.S.C § 1829 and Executive Order 9397, as

amended. Your Social Security Number is requested in order to verify the accuracy of the information in this

application and to differentiate you from other individuals with similar or identical names. The FDIC will use this

information to determine your fitness to participate in the conduct of the affairs of the insured institution, and whether

your affiliation, ownership, control or participation in the conduct of its affairs may constitute a threat to the safety and

soundness of the insured institution or the interests of its depositors or threaten to impair public confidence in the

insured institution. Furnishing the requested information is voluntary, but failure to provide the requested information

in whole or in part may delay or prohibit further evaluation of this application. The information you provide is

protected by the Privacy Act, 5 USC 552(a). 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; and 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 System of Records 30-64-0002, Financial Institutions Investigative and Enforcement Records

available at http://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.

OMB No.: 3064-0018

Expiration Date: 10/31/2021

FEDERAL DEPOSIT INSURANCE CORPORATION

APPLICATION PURSUANT TO SECTION 19

OF THE FEDERAL DEPOSIT INSURANCE ACT

FDIC 6710/07 (10-18)

Page 2

ATLANTA REGIONAL OFFICE

10 Tenth Street, NW

Suite 800

Atlanta, GA 30309-3849

800-765-3342

States Covered: Alabama, Florida, Georgia,

North Carolina, South Carolina, Virginia,

West Virginia

KANSAS CITY REGIONAL OFFICE

1100 Walnut Street

Suite 2100

Kansas City, MO 64106

800-209-7459

States Covered: Iowa, Kansas, Minnesota,

Missouri, Nebraska, North Dakota, South Dakota

BOSTON AREA OFFICE

15 Braintree Hill Office Park

Suite 200

Braintree, MA 02184-8701

866-728-9953

States Covered: Connecticut, Massachusetts,

Maine, New Hampshire, Rhode Island, Vermont

US Territories Covered: Puerto Rico,

Virgin Islands

MEMPHIS AREA OFFICE

6060 Primacy Parkway

Suite 300

Memphis, TN 38119-5770

800-210-6354

States Covered: Arkansas, Louisiana,

Mississippi, Tennessee

CHICAGO REGIONAL OFFICE

300 South Riverside Plaza

Suite 1700

Chicago, IL 60606

800-944-5343

States Covered: Illinois, Indiana, Kentucky,

Michigan, Ohio, Wisconsin

NEW YORK REGIONAL OFFICE

350 Fifth Avenue

Suite 1200

New York, NY 10118

800-334-9593

States Covered: Delaware, District of Columbia,

Maryland, New Jersey, New York, Pennsylvania

DALLAS REGIONAL OFFICE

1601 Bryan Street

Suite 1410

Dallas, TX 75201

800-568-9161 or 214-754-0098

States Covered: Colorado, New Mexico,

Oklahoma, Texas

SAN FRANCISCO REGIONAL OFFICE

25 Jessie Street at Ecker Square

Suite 2300

San Francisco, CA 94105-2780

800-756-3558

States Covered: Alaska, Arizona, California,

Hawaii, Idaho, Montana, Nevada, Oregon, Utah,

Washington, Wyoming

US Territories Covered: American Samoa, Guam,

Federated States of Micronesia

OMB No.: 3064-0018

Expiration Date: 10/31/2021

FEDERAL DEPOSIT INSURANCE CORPORATION

APPLICATION PURSUANT TO SECTION 19

OF THE FEDERAL DEPOSIT INSURANCE ACT

FDIC 6710/07 (10-18) Page 3

Paperwork Reduction Act Notice: The FDIC 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 number. Section 19 of the Federal Deposit Insurance Act (12 U.S.C. § 1829) requires

the FDIC’s written consent prior to any participation in the affairs of an insured depository institution by a person who has been convicted of

crimes involving dishonesty, breach of trust, or money laundering. Individuals or insured depository institutions can seek the FDIC’s written

consent by filing Section 19 Application Form 6710/07. This form distinguishes between applications that are sponsored by an insured

depository institution and applications that submitted by individuals requesting a waiver of the institution sponsorship requirement. The

estimated burden for this collection of information is 16 hours per response. Send comments regarding this burden estimate or any other

aspect of this collection, including suggestions for reducing this burden, to the Paperwork Reduction Officer, Legal Division, Federal Deposit

Insurance Corporation, 550 17

Street, N.W., Washington, D.C. 20429

FDIC GUIDELINES AND POLICIES WITH RESPECT TO SECTION 19 (12 U.S.C. §1829)

On December 2, 1998, the FDIC issued Financial Institution Letter (FIL) 125-98 which announced that the FDIC Board of

Directors had approved a statement of policy (SOP) regarding applications filed pursuant to Section 19 of the Federal Deposit

Insurance Act (12 U.S.C. §1829). The SOP was effective December 1, 1998. The SOP was revised in 2011, 2012, and 2018.

Applicants should review the SOP, these application instructions, and contact the applicable FDIC Regional or Area Office

prior to filing an application. The current SOP can be found at

http://www.fdic.gov/regulations/laws/rules/5000-

1300.html#fdic5000applicationsus.

As amended by the Financial Institutions Reform, Recovery and Enforcement Act of 1989, the Comprehensive Thrift and Bank

Fraud Prosecution and Taxpayer Recovery Act of 1990, and the Financial Services Relief Act of 2006, Section 19 prohibits,

without the prior written consent of the FDIC, a person convicted of any criminal offense involving dishonesty or breach of trust

or money laundering (covered offenses), or who has entered into a pretrial diversion or similar program (program entry) in

connection with a prosecution for such covered offense, from becoming or continuing as an institution-affiliated party, owning

or controlling, directly or indirectly, an insured depository institution, or otherwise participating, directly or indirectly, in the

conduct of the affairs of an insured depository institution (covered person). In addition, Section 19 forbids an insured

depository institution from permitting such a person to engage in any conduct or to continue any relationship prohibited by

Section 19.

The FDIC is precluded from granting consent for ten years, beginning on the date the conviction or agreement of the person

becomes final, to a person convicted of certain crimes enumerated in Title 18 of the United States Code, absent a motion by

the FDIC and approval by the sentencing court. Convictions or program entries for a violation of the Title 18 sections specified

in Section 19 cannot qualify for the de minimis exceptions described below.

Whoever knowingly violates the prohibitions of Section 19 shall be fined not more than $1,000,000 for each day such

prohibition is violated or imprisoned for not more than five years, or both.

De Minimis Rule: Automatic Consent

The SOP provides that consent is automatically granted and an application will not be required where the covered offense is

considered de minimis. The SOP establishes general de minimis criteria where any conviction or program entry for a covered

offense may qualify. The SOP further establishes additional applications in which a de minimis exception will apply under

specified circumstances or for certain specified offenses. The general de minimis rule and the additional applications of de

minimis rules are described below.

(a) De minimis Offenses – In General

Approval is automatically granted and an application will not be required where the covered offense is

considered de minimis, because it meets all of the following criteria:

• There is only one conviction or program entry of record for a covered offense; and

• The offense was punishable by imprisonment for a term of one year or less and/or a fine of $2,500 or less,

and the individual served three (3) days or less of jail time; and

• The conviction or program was entered at least five years before the application; and

• The offense did not involve an insured depository institution or insured credit union.

FEDERAL DEPOSIT INSURANCE CORPORATION

APPLICATION PURSUANT TO SECTION 19

OF THE FEDERAL DEPOSIT INSURANCE ACT

FDIC 6710/07 (10-18) Page 4

The FDIC considers jail time to include any significant restraint on an individual’s freedom of movement

which includes, as part of the restriction, confinement to a specific facility or building on a continuous basis

where the person may leave temporarily only to perform specific functions or during specified times periods

or both. The definition is not intended to include those on probation or parole who may be restricted to a

particular jurisdiction, or who must report occasionally to an individual or to a specified location.

(b) De Minimis Offenses – Additional Applications

Age at Time of Covered Offense

• If the actions that resulted in a covered conviction or program entry of record all occur when the individual

was 21 years of age or younger, then the subsequent conviction or program entry, that otherwise meets the

general de minimis criteria in (a) above, will be considered de minimis if the conviction or program entry was

entered at least 30 months prior to the date an application would otherwise be required, and all sentencing

or program requirements have been met.

Convictions or Program Entries for Insufficient Funds Checks

• Convictions or program entries of record based on the writing of "bad" or insufficient funds check(s) shall be

considered a de minimis offense under this provision and will not be considered as having involved an

insured depository institution if the following applies:

o There is no other conviction or program entry subject to Section 19, and the aggregate total face value

of all “bad” or insufficient funds check(s) cited across all the conviction(s) or program entry(ies) for bad

or insufficient funds checks is $1,000 or less; and

o No insured depository institution or insured credit union was a payee on any of the “bad” or insufficient

funds checks that were the basis of the conviction(s) or program entry(ies).

Convictions or Program Entries for Small-Dollar, Simple Theft

• A conviction or program entry based on a simple theft of goods, services and/or currency (or other monetary

instrument) where the aggregate value of the currency, goods and/or services taken was $500 or less at the

time of conviction or program entry, where the person has no other conviction or program entry under

Section 19, where it has been five years since the conviction or program entry (30 months in the case of a

person 21 or younger as described above) and which does not involve an insured financial institution or

insured credit union is considered de minimis. Simple theft excludes burglary, forgery, robbery, identity

theft, and fraud.

Convictions or Program Entries for the Use of a Fake, False, or Altered Identification Card

• The use of a fake, false, or altered identification card used by a person under the legal age for the purpose

of obtaining or purchasing alcohol, or used for the purpose of entering a premise where alcohol is served but

for which age appropriate identification is required, provided that there is no other conviction or program

entry for a covered offense, will be considered de minimis.

In addition, the SOP requires that any person who meets these criteria must be covered by a fidelity bond to the same extent

as others in similar positions. A person availing themselves of the automatic consent under this provision is required to

disclose the presence of the conviction or program entry to which they have claimed such consent pursuant to the de minimis

criteria to all insured depository institutions in which affairs such person will participate. If an insured depository institution or

person avails themselves of the criteria, the institution should maintain documentation to support the de minimis nature of the

covered crime(s).

Written Application for FDIC Consent

There are two methods by which a covered person can apply to the FDIC for written permission to become an institution-

affiliated party or participate in the affairs of an insured depository institution. The first method involves an insured depository

FEDERAL DEPOSIT INSURANCE CORPORATION

APPLICATION PURSUANT TO SECTION 19

OF THE FEDERAL DEPOSIT INSURANCE ACT

FDIC 6710/07 (10-18) Page 5

institution filing a Section 19 application on behalf of a prospective director, officer, or employee (Sponsorship). When an

insured depository institution will not file a Section 19 application on behalf of a covered person, a second method allows that

individual to seek a waiver of the requirement that an insured depository institution file a Section 19 application on their behalf

(Individual Waiver).

Sponsorship

When an application is required, forms and instructions should be obtained from, and the application filed with, the appropriate

FDIC Regional or Area Office where the sponsoring institution is headquartered (a list of FDIC Offices is included in this

application). Only an insured depository institution may file an application on behalf of a covered person, under Section 19,

unless the FDIC first grants a waiver for an individual to file a Section 19 application on his/her behalf. Sponsorship

applications are generally intended to allow the covered individual to work in a specific job at a specific institution and may also

be subject to the condition that the prior consent of the FDIC will be required for any proposed significant changes in the

person’s duties or responsibilities. Upon FDIC review, such proposed changes may require a new application. Sponsorship

approvals are not transferable to another insured institution. If the FDIC has granted approval for a person to participate in the

affairs of a particular insured institution, and that person subsequently seeks to participate at another insured depository

institution, another application must be submitted.

Individual Waivers

Individual Waivers per Section 19 will be considered on a case-by-case basis where substantial good cause exists for granting

the waiver. Application for an Individual Waiver must be submitted to the appropriate FDIC Regional or Area Office where the

applicant currently resides. Since de minimis offenses may qualify for automatic approval (see de minimis discussion above),

the expectation is that Individual Waivers will be granted on an infrequent basis, and only in truly meritorious cases and upon

good cause shown. For Individual Waivers, the FDIC’s approval results in the issuance of a published order and allows the

covered individual to participate in the affairs of any insured depository institution in any capacity, subject to the FDIC’s

conditions of approval. The approval is limited to the convictions or program entries covered by the order. If such covered

individual is convicted or enters into a pretrial diversion or similar program for a subsequent offense covered by Section 19, he

or she is prohibited from participating in the affairs and of any insured depository institution and must reapply to the FDIC via

the Sponsorship or Individual Waiver process, unless the offense is considered de minimis.

If an individual is seeking a waiver, do not complete Sections A & B of the application. An individual should complete

Sections D-F, and in particular the INDIVIDUAL WAIVER STATEMENT, as well as the INDIVIDUAL WAIVER

CERTIFICATION.

Application Considerations

I. STANDARDS TO BE APPLIED IN DETERMINING WHETHER AN APPLICATION FOR CONSENT IS REQUIRED

UNDER SECTION 19

Section 19 applies to employees of an insured depository institution as well as to any other person who is in a

position to influence control over the management or participate in the affairs of an insured depository institution.

Please note that in addition to the requirement to file an application with the FDIC, some individuals may also need

to comply with any filing requirements established by the Board of Governors of the Federal Reserve System, in

the case of a bank or savings and loan holding company. Absent the FDIC’s written approval, persons covered by

Section 19 are precluded from owning or controlling 25 percent or more of an insured depository institution’s voting

securities, or 10 percent or more of the insured depository institution’s voting securities if that person is the largest

shareholder. The following standards are used in the determination as to whether Section 19 is applicable.

A. There must be a conviction of record. Arrests, pending cases not brought to trial, acquittals, or any conviction

which has been reversed on appeal, or a complete expungement will be excluded from the requirements of

Section 19. For an expungement to be considered complete, the record of conviction must not be intentionally

reserved for a jurisdiction’s subsequent purpose. If an order of expungement has been issued in regard to a

conviction or pretrial diversion (described below) and is intended by the language in the order itself, or in the

legislative provisions under which the order was issued, to be a complete expungement, then the jurisdiction,

either in the order or the underlying legislative provisions, cannot allow the conviction or program entry to be

used for any subsequent purpose including, but not limited to, an evaluation of a person’s fitness or character.

The failure to destroy or seal the records will not prevent the expungement from being considered complete for

the purposes of Section 19 in such a case. A conviction which is being appealed will require a Section 19

application until or unless otherwise reversed. A conviction for which a pardon has been granted will require

FEDERAL DEPOSIT INSURANCE CORPORATION

APPLICATION PURSUANT TO SECTION 19

OF THE FEDERAL DEPOSIT INSURANCE ACT

FDIC 6710/07 (10-18) Page 6

an application. Note: Participation in a pretrial diversion or similar program (program entry) in

connection with a prosecution for a covered offense is included within the provisions of Section 19,

and an application is required. Convictions that are set aside or reversed after the applicant has

completed sentencing will be treated consistent with pretrial diversions or similar programs unless the

court records reflect that the underlying conviction was set aside based on a finding on the merits that

such conviction was wrongful.

Entrance into pretrial diversion or similar program (program entry). A program entry, whether formal or

informal, is characterized by a suspension or eventual dismissal of charges or criminal prosecution often upon

agreement by the accused to treatment, rehabilitation, restitution, or other noncriminal or non-punitive

alternatives. Whether a program constitutes a pretrial diversion or similar program is determined by relevant

federal, state, or local law, and if not so designated under applicable law, then the determination of whether it

is a pretrial diversion or similar program will be made by the FDIC on a case-by-case basis. Expungements of

pretrial diversion or similar program entries will be treated the same as those for convictions. Program entries

prior to November 29, 1990, are not covered by Section 19.

Before an application is considered by the FDIC, all of the sentencing requirements associated with a

conviction or conditions imposed by the pretrial diversion or similar program, including but not limited to,

imprisonment, fines, condition of rehabilitation, and probation requirements, must be completed, and the case

must be considered final by the procedures of the applicable jurisdiction.

B. The conviction or program entry must be for a criminal offense involving dishonesty, breach of trust, or money

laundering. Misdemeanors as well as felonies are included. “Dishonesty” means directly or indirectly to cheat

or defraud, to cheat or defraud for monetary gain or its equivalent, or wrongfully to take property belonging to

another in violation of any criminal statute. Dishonesty includes acts involving lack of integrity; lack of probity;

or a disposition to distort, cheat, or act deceitfully or fraudulently, and may include crimes which federal, state,

or local laws define as dishonest. “Breach of trust” means a wrongful act, use, misappropriation, or omission

with respect to any property or fund which has been committed to a person in a fiduciary or official capacity, or

the misuse of one’s official or fiduciary position to engage in a wrongful act, use, misappropriation, or omission.

Whether a crime involves dishonesty or breach of trust will be determined from the statutory elements of the

crime itself.

Section 19 applies to drug crimes in which money laundering is an element. Whether a crime involving

possession of drugs is covered by Section 19 will be determined by the nature of the crime as defined in the

relevant criminal statute. All convictions for offenses concerning the illegal manufacture, sale, and distribution

of or trafficking in controlled substances shall require an application, unless they fall within the provisions for

de minimis offenses.

C. Youthful Offenders

Adjudgement by a court against a person as a “youthful offender” under any youth offender law or

adjudgement as a “juvenile delinquent” by a family court or any other court having jurisdiction over minors as

defined by state law will not require an application under Section 19. Such adjudications are not considered

convictions for criminal offenses.

D. Adults and All Minors Convicted of Crimes

The conviction of any adult or minor by a court of competent jurisdiction for any criminal offense involving

dishonesty, breach of trust, or money laundering as defined in paragraph B and not excluded under the

automatic consent provision of the de minimis criteria will require an application to, and consent by, the FDIC

prior to an insured depository institution’s employment of such person, or such person owning or controlling,

directly or indirectly, the insured depository institution, or otherwise participating in the affairs of an insured

depository institution.

FEDERAL DEPOSIT INSURANCE CORPORATION

APPLICATION PURSUANT TO SECTION 19

OF THE FEDERAL DEPOSIT INSURANCE ACT

FDIC 6710/07 (10-18) Page 7

II. THE CORPORATION’S POLICY WITH RESPECT TO APPLICATIONS MADE UNDER SECTION 19

A. The essential criteria in assessing an application is whether the person has demonstrated his or her fitness to

participate in the conduct of the affairs of an insured depository institution, and whether the affiliation,

ownership, control, or participation by the person in the conduct of the affairs of the insured depository

institution may constitute a threat to the safety and soundness of the insured depository institution or the

interests of its depositors or threaten to impair public confidence in the insured depository institution. In

determining the degree of risk, the FDIC will consider certain factors for both Sponsorship applications and

Individual Waiver applications. These factors are:

• The conviction or program entry and the specific nature and circumstances of the covered offense;

• Evidence of rehabilitation, including the person's reputation since the conviction or program entry, the

person's age at the time of conviction or program entry, and the time that has elapsed since the conviction

or program entry;

• The position to be held or the level of participation by the person at an insured institution;

• The amount of influence and control the person will be able to exercise over the management or affairs of

an insured institution;

• The ability of management of the insured institution to supervise and control the person's activities;

• The degree of ownership the person will have of the insured institution;

• The applicability of the insured institution's fidelity bond coverage to the person;

• The opinion or position of the primary federal and/or state regulator; and

• Any additional factors in the specific case that appear relevant.

B. These are the important considerations in determining the risk to insured depository institutions. However,

Sponsorship applications differ from Individual Waiver applications in several areas. In a Sponsorship

application, an insured depository institution seeks the FDIC’s consent for the covered individual to participate

only in a specific role at the sponsoring institution. The sponsoring depository institution is aware of the

covered individual’s conviction and rehabilitation history and is willing to sponsor that individual. The

depository institution, in applying on behalf of a covered individual, has agreed to supervise the covered

individual for a specific duty or job range and must ensure the person is covered by the institution’s fidelity

bond to the same extent as others in similar positions. Therefore, the record of rehabilitation for a covered

individual who is sponsored may not be as critical, given the depository institution’s commitment to supervise

that person, versus rehabilitation thresholds for Individual Waiver applications. Furthermore, the degree of

scrutiny accorded a Sponsorship application will be directly proportional to the individual’s proposed position.

C. When evaluating Individual Waiver applications, the FDIC must consider that, upon issuance of an order

granting a waiver and approval, the covered individual will not be barred by Section 19 from holding any

position or participating to any extent in the ownership, affairs, or influence over management of any insured

depository institution. In addition, the FDIC is unable to assess the degree of supervision and controls that

may prospectively exist over the covered individual’s activities at any insured depository institution.

Accordingly, such consent is granted only in meritorious cases where the applicant has demonstrated

substantial good cause and a record of rehabilitation sufficient to mitigate the seriousness of the offense. The

record of rehabilitation must be detailed, commensurate with the seriousness of the offense, and demonstrate

that the individual is fit to participate in the conduct of the affairs of an insured financial institution. Item

number 6 in Section E of this application form provides examples of documentation that may be submitted as

evidence of rehabilitation. Approved Individual Waiver orders are generally subject to conditions. The

conditions typically require the covered individual to provide a copy of the FDIC’s order to all insured

institutions in the affairs of which he or she intends to participate and that the covered individual be covered by

fidelity insurance to the same extent as those who hold similar positions. Other conditions may be imposed as

deemed appropriate.

FEDERAL DEPOSIT INSURANCE CORPORATION

APPLICATION PURSUANT TO SECTION 19

OF THE FEDERAL DEPOSIT INSURANCE ACT

FDIC 6710/07 (10-18) Page 8

If additional space is needed for any information requested by the form, applicants

should attached appropriately labeled additional pages to provide a full response.

SECTION A – INSURED DEPOSITORY INSTITUTION INFORMATION

Note: If an individual is filing this application on his or her own behalf, thereby seeking a

waiver of the requirement that an insured depository institution sponsor the application,

do not complete Sections A and B, and start at Section D.

1. NAME OF THE INSURED DEPOSITORY INSTITUTION

_________________________________________________________________________________________________________

2. DATE OF APPLICATION

_________________________________________________________________________________________________________

3. ADDRESS OF THE INSURED DEPOSITORY INSTITUTION

(Street, City, County, State and Zip Code)

_____________________________________________________________________________________________

SECTION B – POSITION TO BE OCCUPIED BY THE COVERED PERSON IF THEY ARE

A PROSPECTIVE DIRECTOR, OFFICER, OR EMPLOYEE.

1. Title of Position(s) or Prospective Position(s)

__________________________________________________________________________________________________________

2. Describe the duties and responsibilities of the prospective director, officer, or employee. Include extent of supervision

exercised, or potentially exercised, over others and/or by others.

__________________________________________________________________________________________________________

SECTION C – NOTIFICATION OF FIDELITY INSURER

The insured depository institution’s fidelity insurer is to be notified of all pertinent information regarding the conviction of

the prospective employee. Assurances from the fidelity insurer must be obtained, in writing, stating that the prospective

director (if applicable), officer, or employee will be covered by the insured depository institution’s fidelity bond. This

application and the information requested herein may be submitted prior to notification of the bonding company; however, the

FDIC’s consent will be subject to a condition that written assurance of fidelity coverage to the same extent as others in similar

positions be obtained by the insured depository institution.

PROCEED TO SECTION D

FEDERAL DEPOSIT INSURANCE CORPORATION

APPLICATION PURSUANT TO SECTION 19

OF THE FEDERAL DEPOSIT INSURANCE ACT

FDIC 6710/07 (10-18) Page 9

SECTION D – BIOGRAPHICAL INFORMATION OF THE COVERED PERSON*

1. DATE OF APPLICATION

______________________________________________________________________________________________

2. NAME

______________________________________________________________________________________________

3. ADDRESS (Street, City, State and ZIP Code)

______________________________________________________________________________________________

4. TELEPHONE NUMBER AND/OR E-MAIL ADDRESS

______________________________________________________________________________________________

5. DATE OF BIRTH (Month, Day, Year)

______________________________________________________________________________________________

6. PLACE OF BIRTH (City and State)

______________________________________________________________________________________________

7. SOCIAL SECURITY NUMBER

______________________________________________________________________________________________

8. NAME AND ADDRESS OF MOST RECENT EMPLOYER (Street, City, State and ZIP Code)

______________________________________________________________________________________________

9. INDICATE THE TOTAL NUMBER OF VOTING SHARES OF THE INSURED DEPOSITORY INSTITUTION’S (PROPOSED

EMPLOYER) STOCK DIRECTLY OR INDIRECTLY OWNED OR OTHERWISE CONTROLLED BY THE COVERED PERSON.

(Answer “none” if appropriate.)

_______________________________________________________________________________________________

* In addition to a completed Form 6710/07, additional documentation and instructions for the completion of the

fingerprinting process will be provided by the applicant’s respective FDIC Regional or Area Office contact. Further,

other items may be requested and will be identified in the application or sought on a case-by-case basis.

PROCEED TO SECTION E

FEDERAL DEPOSIT INSURANCE CORPORATION

APPLICATION PURSUANT TO SECTION 19

OF THE FEDERAL DEPOSIT INSURANCE ACT

FDIC 6710/07 (10-18) Page 10

If the Applicant is subject to more than one covered offense, attach additional pages

labeled as “SECTION E,” and provide all the information relative to the conviction(s)

or pretrial diversion or similar program(s).

SECTION E – INFORMATION RELATIVE TO CONVICTION(S)

OR PRETRIAL DIVERSION OR SIMILAR PROGRAM(S)

1. DESCRIPTION OR NATURE OF CRIME

___________________________________________________________________________________________________________

2. DATE OF CONVICTION OR DATE OF PRETRIAL DIVERSION OR SIMILAR PROGRAM ENTRY

___________________________________________________________________________________________________________

3. NAME AND ADDRESS OF COURT

___________________________________________________________________________________________________________

4. DISPOSITION

___________________________________________________________________________________________________________

Note: This application covers only those convictions or entry into pretrial diversion or similar programs listed in this Section. If

additional convictions or completion of pretrial diversion or similar programs for crimes involving dishonesty or breach of trust

or money laundering are discovered subsequent to approval of this request, the applicant will be covered by Section 19, and

prohibited from participating in the affairs of an insured depository institution. A subsequent application pursuant to Section

19 will be required.

5. Briefly describe the nature of the offense and the circumstances surrounding it. Include age of prospective employee at the

time of conviction, date of the offense, and any mitigating circumstances (parole, suspension of sentence, pardon, etc.)

___________________________________________________________________________________________________________

6. Briefly describe the extent of rehabilitation of the covered person and attach supporting documents, if any (e.g., a resume,

school transcripts). Evidence of an individual’s rehabilitation may include:

• Subsequent convictions or lack thereof;

• Employment history after conviction or completion of pretrial diversion or similar programs, highlighting any demonstrated

fiduciary responsibility;

• Letter of references from current or former employers, or influential members of the community, or probation or parole

officers;

• Subsequent educational achievements, if any. Documentation must be provided to support any educational achievement.

• If currently going to school, letter of references from a professor, dean, or other school official;

• Community service or volunteer work.

Note: Please provide contact information for individuals who may be contacted to verify evidence of rehabilitation for each item you

wish to have considered as evidence of your rehabilitation. References have greater weight when the party providing the

reference is aware of the individual’s prior history.

__________________________________________________________________________________________________________

FEDERAL DEPOSIT INSURANCE CORPORATION

APPLICATION PURSUANT TO SECTION 19

OF THE FEDERAL DEPOSIT INSURANCE ACT

FDIC 6710/07 (10-18) Page 11

(Section E continued)

7. Attach copies of the Indictment, Information, or Complaint and Final Decree of Judgment, or documentation to support the

completion of a Pretrial Diversion or Similar Program, if available. (Normally these can be obtained from the clerk of the court

or prosecutor’s office. If not provided, explain reasons for unavailability.)

___________________________________________________________________________________________________________

8. List any other pertinent facts relative to the crime which are not disclosed in the Indictment, Information, or Complaint and Final

Decree of Judgment.

___________________________________________________________________________________________________________

I understand that the FDIC may conduct extensive checks into my background, experience, and related matters in conjunction with

my application. I consent to and authorize collection agencies, credit bureaus, law enforcement agencies, consumer reporting

agencies, and other sources of information to provide information about me including, but not limited to, financial, credit, tax,

immigration, and criminal investigative information to the FDIC for the purpose of making a determination as to my experience,

competence, integrity, character, financial ability, and willingness to direct, lead or participate in a bank’s affairs in a safe, sound,

and legal manner. I do hereby certify that the Biographical Information (Section D) and Information Relative to Conviction(s) or

Pretrial Diversion or Similar Program (Section E) are true and correct to the best of my knowledge and belief.

_________________________________________________________

NAME OF COVERED PERSON (Type or Print)

_________________________________________________________ ____________________________

SIGNATURE OF COVERED PERSON DATE SIGNED (Month, Day, Year)

NOTE: The information requested in Sections D and E above, including the Social Security Number of the covered person is

solicited pursuant to Section 19 of the Federal Deposit Insurance Act (12 U.S.C. 1829). This information is necessary to

assist the FDIC in assessing the merits of the application. Some of the information, including the Social Security Number,

may be provided to any appropriate federal or state insured depository institution regulatory agency and law enforcement

or other governmental agencies for identity verification purposes. Should the information indicate a violation of law, the

application may be referred to any agency responsible for investigating or prosecuting such a violation. In addition, in the

event of litigation, the application may be presented to the appropriate court as evidence and to counsel in the course of

discovery. While submission of the information is voluntary, an omission or inaccuracy may result in a delay in processing

the application, a return of the application as incomplete, or a denial of the application. Falsification of any of the

information may serve as a basis for denial of the application or the removal of the director, officer, or employee if

employed by the insured depository institution as well as grounds for criminal charges.

INSURED DEPOSITORY INSTITUTIONS SHOULD PROCEED TO SECTION F

INDIVIDUAL APPLICANTS SHOULD PROCEED TO SECTION G

FEDERAL DEPOSIT INSURANCE CORPORATION

APPLICATION PURSUANT TO SECTION 19

OF THE FEDERAL DEPOSIT INSURANCE ACT

FDIC 6710/07 (10-18) Page 12

SECTION F – ADDITIONAL INFORMATION IN SUPPORT OF THIS REQUEST

Insured depository institutions may list any other appropriate information. (Enter “NONE” if desired.)

INSURED DEPOSITORY INSTITUION SHOULD PROCEED TO THE CERTIFICATION FOR APPLICATION

SECTION G – INDIVIDUAL WAIVER STATEMENT

If an individual is seeking a waiver of the requirement that an insured depository financial institution file a Section 19 application on

his/her behalf, provide a summary statement in the space below describing why the FDIC should grant the waiver of the institution

filing requirement in their case. (Use additional sheets if needed)

INDIVIDUAL APPLICANTS SHOULD PROCEED TO THE INDIVIDUAL CERTIFICATION FOR WAIVER AND APPLICATION

FEDERAL DEPOSIT INSURANCE CORPORATION

APPLICATION PURSUANT TO SECTION 19

OF THE FEDERAL DEPOSIT INSURANCE ACT

FDIC 6710/07 (10-18) Page 13

FOR INSURED DEPOSITORY INSTITUTION CERTIFICATION FOR APPLICATION

I do hereby certify that the Board of Directors adopted a resolution which delegated the undersigned the authority to make

applications pursuant to Section 19 of the Federal Deposit Insurance Act or has adopted a resolution authorizing this application

pursuant to Section 19 of the Federal Deposit Insurance Act.

________________________________________________________________________

NAME AND TITLE OF INSURED DEPOSITORY INSTITUTION OFFICIAL (Type or Print)

_____________________________________________________________ _____________________

SIGNATURE OF INSURED DEPOSITORY INSTITUTION OFFICIAL DATE (Month, Day, Year)

FOR INDIVIDUAL CERTIFICATION FOR WAIVER AND APPLICATION

To be signed by the individual seeking a waiver of the requirement that an insured depository institution file a Section 19 application

on his/her behalf

I certify that, to the best of my knowledge and belief, all of the information on and attached to this waiver application is true, correct,

and complete and provided in good faith. I understand that falsification of any of the information may serve as a basis for my

removal as an employee of an insured depository institution and as grounds for criminal charges. I understand that any information

I give may be investigated. I further understand that any decision made regarding my individual waiver and application will be a

public document, and will be posted on the FDIC’s website.

_______________________________________________________________________

INDIVIDUAL SEEKING WAIVER (Type or Print)

_____________________________________________________________ _____________________

SIGNATURE OF INDIVIDUAL SEEKING WAIVER DATE (Month, Day, Year)

This is an official document of the Federal Deposit Insurance Corporation. Providing false information may

be grounds for prosecution under the provisions of Title 18, Section 1001 or 1007 of the United States Code

and may be punishable by fine or imprisonment.

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