+----------------------------------------------------------------------+
| **PRIVACY ACT NOTICE**                                               |
+----------------------------------------------------------------------+
| AUTHORITY: Collection of this information is authorized by Executive |
| Order 9397 and by section 12(f)(4) of the Federal Deposit Insurance  |
| Act, 12 U.S.C. § 1822(F)(4) as amended by section 19 of Public Law   |
| 103-204. The information requested on this form will be used to      |
| determine your eligibility for employment with the Federal Deposit   |
| Insurance Corporation (FDIC). The information may be disclosed       |
| outside the FDIC in accordance with the routine uses listed below.   |
| Your social security number (SSN) is requested to ensure that our    |
| records are accurate since other people may have the same name or    |
| birth date. Your completion of this form, including the provision of |
| your SSN, is voluntary; however, your application cannot be          |
| processed, and you will be ineligible for employment with the FDIC,  |
| if you do not provide the requested information.                     |
+----------------------------------------------------------------------+
| **PRIVACY ACT ROUTINE USES**                                         |
+----------------------------------------------------------------------+
| # This record a                                                      |
| nd information in this record may be used in disclosing information: |
|                                                                      |
| \- To designated officers and employees of agencies, offices, and    |
| other establishments in the executive, legislative, and judicial     |
| branches of the Federal Government, having a need to evaluate        |
| qualifications, suitability, and loyalty to the United States        |
| Government and/or a security clearance or access determination       |
|                                                                      |
| -   To designated officers and employees of agencies, offices, and   |
|     other establishments in the executive, legislative, and judicial |
|     branches of the Federal Government, and the District of Columbia |
|     Government, when such agency, office, or establishment conducts  |
|     an investigation of the individual for purposes of granting a    |
|     security clearance, or for the purpose of making a determination |
|     of qualifications, suitability, or loyalty to the United States  |
|     Government, or access to classified information or restricted    |
|     areas;                                                           |
|                                                                      |
| -   \- To designated officers and employees of agencies, offices,    |
|     and other establishments in the executive, judicial, or          |
|     legislative branches of the Federal Government having the        |
|     responsibility to grant clearances, to make a determination      |
|     regarding access to classified information or restricted areas,  |
|     or to evaluate qualifications, suitability, or loyalty to the    |
|     United States Government in connection with performance of a     |
|     service to the Federal Government under a contract or other      |
|     agreement;                                                       |
|                                                                      |
| -   To intelligence agencies for use in intelligence activities;     |
|                                                                      |
| -   To any source from which information is requested in the course  |
|     of an investigation, to the extent necessary to identify the     |
|     individual, inform the source of the nature and purpose of the   |
|     investigation, and to identify the type of information           |
|     requested;                                                       |
|                                                                      |
| -   To the Federal, State, or local agency responsible for           |
|     investigating, prosecuting, enforcing, or implementing a         |
|     statute, rule regulation, or order where there is an indication  |
|     of a violation or potential violation of civil or criminal law   |
|     or regulation;                                                   |
|                                                                      |
| -   To an agency, office or other establishment in the executive,    |
|     legislative, or judicial branches of the Federal Government, or  |
|     the District of Columbia Government, in response to its request, |
|     in connection with the hiring or retention 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, or the issuance of a         |
|     license, grant, or other benefit by the requesting agency;       |
|                                                                      |
| -   To Federal agencies as a data source for management information  |
|     through the production of summary descriptive statistics and     |
|     analytical studies in support of the functions for which the     |
|     records are maintained or for related studies;                   |
|                                                                      |
| -   To a Congressional Office in response to an inquiry made at the  |
|     request of that individual;                                      |
|                                                                      |
| -   In litigation before a court or in an administrative proceeding  |
|     being conducted by a Federal agency;                             |
|                                                                      |
| -   To the National Archives and Records Administration for records  |
|     management inspections;                                          |
|                                                                      |
| -   To the Office of Management and Budget in connection with        |
|     private relief legislation;                                      |
|                                                                      |
| -   To respond to a request for discovery or for appearance of a     |
|     witness; and                                                     |
|                                                                      |
| -   To the Merit Systems Protection Board, the Office of Special     |
|     Counsel, the Equal Employment Opportunity Commission, or the     |
|     Federal Labor Relations Authority, in connection with functions  |
|     vested in those agencies.                                        |
|                                                                      |
| **ESTIMATED REPORTING BURDEN**                                       |
|                                                                      |
| Public reporting burden for this collection of information is        |
| estimated to average [20]{.underline} minutes per response,          |
| including the time for reviewing instructions, searching existing    |
| data sources, gathering and maintaining the data needed, and         |
| completing and reviewing the collection of information. Send         |
| comments regarding this burden estimate or any other aspect of this  |
| collection of information, including suggestions for reducing this   |
| burden, to the Paper Reduction Act Clearance Officer, Legal          |
| Division, Federal Deposit Insurance Corporation, 550 17^th^ Street,  |
| N.W., Washington, DC 20429; and to the Office of Management and      |
| Budget, Paperwork Reduction Project (3064-0121), Washington, D.C.    |
| 20503. An agency may not conduct nor sponsor, and a person is not    |
| required to respond to, a collection of information unless it        |
| displays a currently valid OMB control number.                       |
+----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| # FRAUD OR FRAUDULENT STATEMENT NOTICE                                |
+-----------------------------------------------------------------------+
| Falsification of any answer may result in a fine of not more than     |
| \$10,000 or imprisonment for not more than 5 years or both            |
|                                                                       |
| (18 U.S.C. § 1001)                                                    |
+-----------------------------------------------------------------------+
| # DEFINITIONS                                                         |
+-----------------------------------------------------------------------+
| 1\. **"Felony"** is any violation of law punishable by imprisonment   |
| of longer than one year, except for violations called misdemeanors    |
| under state law which are punishable by imprisonment of two years or  |
| less.                                                                 |
|                                                                       |
| 2\. **"Company"** is any individual, corporation, partnership, joint  |
| venture, business trust, association or similar organization, or any  |
| other trust unless by its terms it must terminate within 25 years or  |
| not later than 21 years and ten months after the death of individuals |
| living on the effective date of the trust, but shall not include any  |
| corporation the majority of the shares of which are owned by the      |
| United States, any state, or the District of Columbia.                |
|                                                                       |
| 3\. **"Control"** means:                                              |
|                                                                       |
| > a\. The power to vote, directly or indirectly, 25 percent or more   |
| > of any class of the voting stock of a company, the ability to       |
| > direct in any manner the election of a majority of a company's      |
| > directors or trustees, or the ability to exercise a controlling     |
| > influence over the company's management and policies. For purposes  |
| > of this definition, a general partner of a limited partnership is   |
| > presumed to be in control of that partnership.                      |
| >                                                                     |
| > b\. An entity or individual shall be presumed to have control of a  |
| > company if the entity or individual directly or indirectly, or      |
| > acting in concert with one or more entities or individuals, or      |
| > through one or more subsidiaries, owns or controls 25 percent or    |
| > more of its equity, or otherwise controls or has power to control   |
| > its management or policies.                                         |
|                                                                       |
| 4\. \"Default on material obligation\" is a loan or advance from an   |
| insured depository institution which is or has been delinquent        |
|                                                                       |
| for 90 or more days as to payment of principal and/or interest.       |
|                                                                       |
| 5\. **"Insured depository institution"** is any bank or savings       |
| association the deposits of which are insured by a Federal Deposit    |
| Insurance Fund administered by the FDIC.                              |
|                                                                       |
| 6\. **"Pattern or Practice of Defalcation regarding obligations"**    |
| means:                                                                |
|                                                                       |
| > a\. A history of financial irresponsibility with regard to debts    |
| > owed to insured depository institutions which are in default in     |
| > excess of \$50,000 in the aggregate. Examples of such financial     |
| > irresponsibility include, without limitation:                       |
|                                                                       |
| \(1\) Failure to pay a debt or debts totaling more than \$50,000      |
| secured by an uninsured property which is destroyed; or               |
|                                                                       |
| > \(2\) Abuse of credit cards or incurring excessive debt well beyond |
| > the individual\'s ability to repay resulting in default(s) in       |
| > excess of \$50,000 in the aggregate.                                |
| >                                                                     |
| > b\. Wrongful refusal to fulfill duties and obligations to insured   |
| > depository institutions. Examples of such wrongful refusal to       |
| > fulfill duties and obligations include, without limitation:         |
|                                                                       |
| \(1\) Any use of false financial statements;                          |
|                                                                       |
| \(2\) Misrepresentation as to the individual\'s ability to repay      |
| debts;                                                                |
|                                                                       |
| \(3\) Concealing assets from the insured depository institution;      |
|                                                                       |
| > \(4\) Any instance of fraud, embezzlement or similar misconduct in  |
| > connection with an obligation to the insured depository             |
| > institution; or                                                     |
|                                                                       |
| \(5\) Any conduct described in any civil or criminal judgment against |
| an individual for breach of any obligation, contractual or otherwise, |
| or any duty of loyalty or care that the individual owed to an insured |
| depository institution.                                               |
|                                                                       |
| 7\. **"Substantial Loss to Federal Deposit Insurance Funds"** is :    |
|                                                                       |
| > a\. A loan or advance from an insured depository institution, which |
| > is now owed to the Federal Deposit Insurance Corporation (FDIC),    |
| > Resolution Trust Corporation (RTC), Federal Savings Loan Insurance  |
| > Corporation (FSLIC) or their successors, or any Federal deposit     |
| > insurance fund, that is delinquent for ninety (90) or more days as  |
| > to payment of principal, interest, or a combination thereof and on  |
| > which there remains a legal obligation to pay an amount in excess   |
| > of \$50,000;                                                        |
| >                                                                     |
| > b\. A final judgment in excess of \$50,000 in favor of any Federal  |
| > deposit insurance fund, the FDIC, RTC, or FSLIC, or their           |
| > successors regardless of whether it becomes forgiven in whole or in |
| > part in a bankruptcy proceeding;                                    |
|                                                                       |
| c\. For purposes of computing the \$50,000 ceiling above, all         |
| delinquent judgments, loans, or advances currently owed to the FDIC,  |
| RTC, FSLIC, or their successors, or any Federal deposit insurance     |
| fund, shall be aggregated. In no event shall delinquent loans or      |
| advances from different insured depository institutions be separately |
| considered.                                                           |
+-----------------------------------------------------------------------+

+---------------------------+--------+----------------------+---+----+
| # Federal Depo            |        | NAME                 |   |    |
| sit Insurance Corporation |        |                      |   |    |
|                           |        |                      |   |    |
| ## APPLICAN               |        |                      |   |    |
| T CERTIFICATION STATEMENT |        |                      |   |    |
+---------------------------+--------+----------------------+---+----+
|                           |        |                      |   |    |
+---------------------------+--------+----------------------+---+----+
|                           |        | SOCIAL SECURITY      |   |    |
|                           |        | NUMBER               |   |    |
+---------------------------+--------+----------------------+---+----+
|                           |        | \*\*\* - \*\* -      |   |    |
+---------------------------+--------+----------------------+---+----+
| # Federal Depo            |        |                      |   |    |
| sit Insurance Corporation |        |                      |   |    |
|                           |        |                      |   |    |
| **Certification of        |        |                      |   |    |
| Compliance with Section   |        |                      |   |    |
| 12(f)(4)**                |        |                      |   |    |
|                           |        |                      |   |    |
| **of the Federal Deposit  |        |                      |   |    |
| Insurance Act (12 U.S.C.  |        |                      |   |    |
| § 1822(f)(4))**           |        |                      |   |    |
|                           |        |                      |   |    |
| **as amended by Section   |        |                      |   |    |
| 19 of Public Law          |        |                      |   |    |
| 103-204**                 |        |                      |   |    |
|                           |        |                      |   |    |
| **NOTICE:** Furnishing    |        |                      |   |    |
| the information requested |        |                      |   |    |
| on this form is a         |        |                      |   |    |
| condition of employment   |        |                      |   |    |
| for all applicants prior  |        |                      |   |    |
| to appointment with the   |        |                      |   |    |
| Federal Deposit Insurance |        |                      |   |    |
| Corporation. **Please     |        |                      |   |    |
| read the Privacy Act      |        |                      |   |    |
| Notice, Privacy Act       |        |                      |   |    |
| Routine Uses, and the     |        |                      |   |    |
| definitions on page 2 of  |        |                      |   |    |
| this form before          |        |                      |   |    |
| answering the following   |        |                      |   |    |
| questions.** If you wish  |        |                      |   |    |
| to discuss any of the     |        |                      |   |    |
| definitions or questions  |        |                      |   |    |
| on this form prior to     |        |                      |   |    |
| submission you may seek   |        |                      |   |    |
| guidance from the Ethics  |        |                      |   |    |
| Unit, Legal Division,     |        |                      |   |    |
| telephone (202) 898-7287. |        |                      |   |    |
|                           |        |                      |   |    |
| The Federal Deposit       |        |                      |   |    |
| Insurance Corporation is  |        |                      |   |    |
| prohibited by statute     |        |                      |   |    |
| from employing any person |        |                      |   |    |
| who does not meet minimum |        |                      |   |    |
| competence, experience,   |        |                      |   |    |
| integrity, and fitness    |        |                      |   |    |
| requirements. No person   |        |                      |   |    |
| shall become employed     |        |                      |   |    |
| performing the            |        |                      |   |    |
| responsibilities of or    |        |                      |   |    |
| for the Federal Deposit   |        |                      |   |    |
| Insurance Corporation who |        |                      |   |    |
| must respond YES to any   |        |                      |   |    |
| of the following          |        |                      |   |    |
| questions. **Further, you |        |                      |   |    |
| are advised that the      |        |                      |   |    |
| Federal Deposit Insurance |        |                      |   |    |
| Corporation cannot retain |        |                      |   |    |
| employees who are not in  |        |                      |   |    |
| compliance with the       |        |                      |   |    |
| prohibitions listed in    |        |                      |   |    |
| Part I, below, anytime    |        |                      |   |    |
| after June 17, 1994.**    |        |                      |   |    |
+---------------------------+--------+----------------------+---+----+
| # PART I -                |        |                      |   |    |
| - EMPLOYMENT REQUIREMENTS |        |                      |   |    |
+---------------------------+--------+----------------------+---+----+
| #                         |        |                      | Y | NO |
|                           |        |                      | E |    |
|                           |        |                      | S |    |
+---------------------------+--------+----------------------+---+----+
| 1\. Have you been         |        |                      |   |    |
| convicted of a felony?    |        |                      |   |    |
|                           |        |                      |   |    |
+---------------------------+--------+----------------------+---+----+
| 2\. Have you been removed |        |                      |   |    |
| from, or prohibited from  |        |                      |   |    |
| participating in the      |        |                      |   |    |
| affairs of, any insured   |        |                      |   |    |
| depository institution(s) |        |                      |   |    |
| pursuant to any final     |        |                      |   |    |
| enforcement action by any |        |                      |   |    |
| federal banking agency?   |        |                      |   |    |
+---------------------------+--------+----------------------+---+----+
| 3\. Have you demonstrated |        |                      |   |    |
| a pattern or practice of  |        |                      |   |    |
| defalcation regarding     |        |                      |   |    |
| obligations to insured    |        |                      |   |    |
| depository institutions?  |        |                      |   |    |
+---------------------------+--------+----------------------+---+----+
| 4. Have you caused a      |        |                      |   |    |
| substantial loss to       |        |                      |   |    |
| federal deposit insurance |        |                      |   |    |
| funds?                    |        |                      |   |    |
+---------------------------+--------+----------------------+---+----+
| **PART II -- INFORMATION  |        |                      |   |    |
| ON DEFAULTS**             |        |                      |   |    |
+---------------------------+--------+----------------------+---+----+
| Any candidate for         |        |                      |   |    |
| employment shall submit a |        |                      |   |    |
| list and description of   |        |                      |   |    |
| all instances during the  |        |                      |   |    |
| five (5) years preceding  |        |                      |   |    |
| the submission of an      |        |                      |   |    |
| application for           |        |                      |   |    |
| employment in which the   |        |                      |   |    |
| person or a company under |        |                      |   |    |
| such person's control     |        |                      |   |    |
| defaulted on a material   |        |                      |   |    |
| obligation to an insured  |        |                      |   |    |
| depository institution.   |        |                      |   |    |
| Provide complete          |        |                      |   |    |
| information regarding any |        |                      |   |    |
| default, include the      |        |                      |   |    |
| total dollar amount,      |        |                      |   |    |
| financial institution,    |        |                      |   |    |
| dates, and final judgment |        |                      |   |    |
| or current status of the  |        |                      |   |    |
| obligation on a separate  |        |                      |   |    |
| page, and attach in       |        |                      |   |    |
| duplicate to this form,   |        |                      |   |    |
| including your name,      |        |                      |   |    |
| Social Security Number,   |        |                      |   |    |
| and original signature on |        |                      |   |    |
| each page of the          |        |                      |   |    |
| attachment. **Please      |        |                      |   |    |
| check the appropriate box |        |                      |   |    |
| below:**                  |        |                      |   |    |
|                           |        |                      |   |    |
| I have **not** defaulted  |        |                      |   |    |
| on a material obligation  |        |                      |   |    |
| or caused any loss as     |        |                      |   |    |
| defined on the reverse    |        |                      |   |    |
| within the last 5 years;  |        |                      |   |    |
| therefore, I have not     |        |                      |   |    |
| prepared an attachment.   |        |                      |   |    |
|                           |        |                      |   |    |
| **I have attached details |        |                      |   |    |
| regarding all defaults in |        |                      |   |    |
| the preceding 5 years.**  |        |                      |   |    |
+---------------------------+--------+----------------------+---+----+
| **PART III --             |        |                      |   |    |
| CERTIFICATION**           |        |                      |   |    |
+---------------------------+--------+----------------------+---+----+
| I certify that I have     |        |                      |   |    |
| read the definitions,     |        |                      |   |    |
| which are a part of this  |        |                      |   |    |
| form, and that the        |        |                      |   |    |
| statements I have made on |        |                      |   |    |
| this certification are    |        |                      |   |    |
| true, complete, and       |        |                      |   |    |
| correct to the best of my |        |                      |   |    |
| knowledge and belief.     |        |                      |   |    |
| During the term of any    |        |                      |   |    |
| employment I may have     |        |                      |   |    |
| with the Federal Deposit  |        |                      |   |    |
| Insurance Corporation, I  |        |                      |   |    |
| will immediately provide  |        |                      |   |    |
| the Ethics Unit with a    |        |                      |   |    |
| written explanation of    |        |                      |   |    |
| any facts or              |        |                      |   |    |
| circumstances which would |        |                      |   |    |
| cause these answers to    |        |                      |   |    |
| change.                   |        |                      |   |    |
+---------------------------+--------+----------------------+---+----+
| Signature of Applicant    | Date   | Identify             |   |    |
|                           |        | Announcement Number  |   |    |
|                           |        | for which you have   |   |    |
|                           |        | applied, or Position |   |    |
|                           |        | Title, Grade, and    |   |    |
|                           |        | Organizational       |   |    |
|                           |        | Location:            |   |    |
+---------------------------+--------+----------------------+---+----+
|                           |        |                      |   |    |
+---------------------------+--------+----------------------+---+----+