Minority Bank Deposit Program

Minority Bank Deposit Program Financial Institution Certification Form for Admission

OMB No. 15100048 Exp. Date 00/00/00

NOTE: Due to the sensitivity of this information, ONLY recertifications will be accepted by electronic form. Incomplete forms may be rejected.

If you are new financial institution, please send form by mail.

I am applying for participation in the Minority Bank Deposit Program (MBDP) administered by the U.S. Department of the Treasury, Financial Management Service.

Institution Name (required)
Address: (required)
City/State/Zip: (required)
Telephone No.: (required)
Fax No.:
E-mail: (required)
Routing & Transit Number (ABA #): (required)

Number of shares owned by each of the following groups:

African Americans:
Hispanic:
Eskimos:
Asian Americans:
Native American:
Aleuts:
Caucasian Women:
Low Income Credit Union:
Other Minorities (Please Specify):
Total Shares:
Total Minority Shares:
Percentage of Minority Ownership:

If applying under the control criteria, in addition to completing items 1-6, attach copies of executed voting trust and/or proxy agreements. These agreements must have a life of at least three years, be irrevocable, and the trustee (a member of a minority group) must have unfettered discretion in voting the stock. Please mail this documentation to:

Federal Reserve Bank of St. Louis
Attn: Treasury Support Center Analysts
PO Box 442
St. Louis, MO 63166

I hereby certify that each member of a minority or women's group is either a U.S. citizen or a U.S. resident.

I agree that, after acceptance into the MBDP, the institution shall immediately notify the Financial Management Service (FMS) of any change in ownership and/or control that could affect program eligibility.

I agree that if the institution provides erroneous information or fails to notify FMS of any changes in ownership and/or control which render the institution ineligible to participate in the MBDP, the institution shall lose all rights to benefits that are being received as a result of its status as a MBDP participant, and if the institution receives funds, including but not limited to the Treasury Tax & Loan non-interest bearing deposit from FMS, it shall return such funds to FMS and shall reimburse FMS for the imputed value of the funds at the Federal funds rate less 25 basis points from the time that the institution becomes ineligible for the MBDP until such funds are received by FMS.

I hereby certify that all of the above information is true and accurate, and I understand that any misrepresentation of fact is subject to the criminal code provisions of Title 18, Section 1001 of the United States Code.

I hereby certify that the above named official(s) are authorized to release collateral:

Name:
Title:
Date:

Department of the Treasury
Financial Management Service

Last Updated: Thursday March 06, 2008


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