OMB No. for FDIC 3064-0006

OMB No. for FRB 7100-0134

OMB No. for OCC 1557-0014

OMB Nos. for OTS 1550-0005, -0015, -0047

Expiration Date: 02/29/2008

## INTERAGENCY BIOGRAPHICAL AND FINANCIAL REPORT

Public reporting burden for this collection of information is estimated
to average two hours for biographical information and two 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, 550 17th
Street, NW, Washington, DC 20429; Secretary, Board of Governors of the
Federal Reserve System, 20th and C Streets, NW, Washington, DC 20551;
Licensing Activities Division, Comptroller of the Currency, 250 E
Street, S.W., Washington, DC 20219; or Office of Supervision Policy,
Office of Thrift Supervision, 1700 G Street, N.W., Washington, DC 20552;
and to the Office of Management and Budget, 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 regulatory agency. This report is *not* a stand-alone
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 regulatory agency will provide
additional instructions for use and preparation. If the report is not
complete, the regulatory 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 regulatory agency specifically reserves the right to
require up to five years of financial data from any acquiring person 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.

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 regulatory agency\'s
procedural guidelines (that is, the *Comptroller\'s Licensing Manual*,
the FDIC\'s Rules and Regulations (12 C.F.R. Part 303), or the OTS\'
*Application Processing Handbook*), contact the agency directly for
specific instruction, or visit its Web site at
[www.occ.treas.gov](http://www.occ.treas.gov/),
[www.fdic.gov](http://www.fdic.gov/),
[www.ots.treas.gov](http://www.ots.treas.gov/), or
[www.federalreserve.gov](http://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 o*wner* 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 (5 U.S.C. section 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 regulatory 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."

***INTERAGENCY BIOGRAPHICAL AND FINANCIAL REPORT***

This is filed with respect to:

     

Name of Subject Institution or Holding Company, Location

> **Type of Filing Position**

  --- ------------------------------------- ---- --------------------------
      Bank or Thrift Charter                     Organizer

      Bank or Thrift Holding Company             Director

      Change in Bank Control                     Senior Executive Officer

      Change in Senior Executive Officer or      Title: [     ]{.underline}
      Director                                   

      Citizenship Waiver                         Principal Shareholder

      Charter Conversion                         Trustee

      Deposit Insurance                          Manager

      Federal Branch or Agency                   Manager

      Other [     ]{.underline}                  Other [     ]{.underline}
  --- ------------------------------------- ---- --------------------------

**BIOGRAPHICAL REPORT**

**1. Personal Information**

  ----------- ------- ------------- -- --------- -- ------- -- -------- -- -- ------------ -- ---------------
  \(a\) Name                                                                                  

              Last                                  First                     (Middle-no      
                                                                              initials)       

                                                                                              

  \(b\)                                                                                       
  Residence                                                                                   

                      (Street                                                                 
                      Address)                                                                

                                                                                                   

                      (City)           (State)                 (ZIP                           (Country)
                                                               Code)                          
  ----------- ------- ------------- -- --------- -- ------- -- -------- -- -- ------------ -- ---------------

\(c\) If at residence less than five years, list addresses and dates
occupied for past five years.

  ------------------- ----------------- --------------------- --------------------- ------------------- -----------------------
  [Date               [Date             [Number and           [State]{.underline}   [ZIP                [Country]{.underline}
  From]{.underline}   To]{.underline}   Street]{.underline}                         Code]{.underline}   

                                                                                                             

                                                                                                             

                                                                                                             

                                                                                                             

                                                                                                             
  ------------------- ----------------- --------------------- --------------------- ------------------- -----------------------

  ------------- --------- -------- --------------- -- ------- --------- -- -------------- -- -- ------- -- ------------------
  \(d\) Date of           Month:                      Day:                                      Year:      
  Birth:                                                                                                   

                                                                                                           

                                                                                                           

  \(e\) Place                                                                                                   
  of Birth:                                                                                                

                                   (City)                     (State)                                      (Country)

                                                                                                           

  \(f\) United                                                                                             
  States Social                                                                                            
  Security                                                                                                 
  Number:                                                                                                  

                                                                                                           

  \(g\)                                                                                                    
  Citizenship                                                                                              

                Country                                                    (Date, if                       
                                                                           Naturalized)                    
  ------------- --------- -------- --------------- -- ------- --------- -- -------------- -- -- ------- -- ------------------

\(h\) If not a United States citizen, provide:

Passport Number:      

> Home Country Identification Number:      

Immigration File Number:      

Father\'s full name      

Mother\'s full name, including maiden name      

\(i\) Telephone and fax numbers where you may be reached during business
hours and an e-mail address:

>      
>
> (Area Code, Telephone Number, including Country Code if outside U.S.)

  ----------------------------------- -----------------------------------
                                           

  (Fax Number)                        E-mail Address
  ----------------------------------- -----------------------------------

\(j\) 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.

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  -----------------------------------------------------------------------

2.  **Employment Record**

> \(a\) List employment in reverse chronological order for the last five
> years. The list should include the beginning and ending dates of
> employment, the employer's name and location (city, state), nature of
> business, title or position, nature of duties, and 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 employer's name, address, and telephone number;
> title or position; date of discharge; and explanation.

  -----------------------------------------------------------------------
       

       

       
  -----------------------------------------------------------------------

**3. Education and Professional Credentials**

(a) List each diploma or degree from high schools, colleges,
    universities, or other schools.

  ---------------------------- -------------------- ------------------ ----------------------
  [School\'s                   [From]{.underline}   [To]{.underline}   [Degree]{.underline}
  Name/Location]{.underline}                                           

                                                                       

                                                                            

                                                                            

                                                                            

                                                                            
  ---------------------------- -------------------- ------------------ ----------------------

(b) List each professional license or similar certificate you now hold
    or have held (for example, Attorney, Physician, CPA, NASD or SEC
    registration).

  ----------------------- ------------------------ --------------------- ---------------------- --------------------------
  [License]{.underline}   [Issuing                 [Date                 [Status]{.underline}   [Expiration]{.underline}
                          Authority]{.underline}   Issued]{.underline}                          

                                                                                                     

                                                                                                     

                                                                                                     

                                                                                                     

                                                                                                     
  ----------------------- ------------------------ --------------------- ---------------------- --------------------------

**4. Business and Banking Affiliations**

> \(a\) List any company with which you are associated, providing the
> company name, location, nature or type of business, position held or
> relationship to the company, ownership percentage, and beginning date
> of the relationship.

  -----------------------------------------------------------------------
     

  -----------------------------------------------------------------------

> \(b\) List the name of any depository institution or depository
> institution holding company with which you are or were associated.
> Also list the location, nature of banking activity, position held or
> relationship, ownership percentage, and beginning and ending dates of
> the relationship.

  -----------------------------------------------------------------------
       

  -----------------------------------------------------------------------

Are you in the process of being considered for a senior executive
officer or director position at another depository institution or
depository institution holding company?

> Yes No
>
> 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
> regulatory agency.

  -----------------------------------------------------------------------
       

  -----------------------------------------------------------------------

> \(d\) Are you now or are you proposed to be a "management official" of
> another insured depository institution or depository institution
> holding company? 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.

  -----------------------------------------------------------------------
       

  -----------------------------------------------------------------------

**5. Legal and Related Matters**

\(a\) 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:

> \(1\) Acharter 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? Yes No
>
> \(2\) A merger application in which you were listed as a director,
> senior executive officer, or similar position? Yes No
>
> \(3\) 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? Yes No
>
> \(4\) 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?
> Yes No

(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? Yes No

\(b\) 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

\(c\) Has any depository institution with which you are or were
associated:

(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

(c) Have you or any company with which you are or were associated:

    1.  Filed a petition under any chapter of the Bankruptcy Code or had
        an involuntary bankruptcy petition filed against you or the
        company? Yes No

\(2\) 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?
>
> Yes No
>
> \(4\) Had a lien placed against property for failure to pay taxes or
> other debts?
>
> Yes No
>
> \(5\) Had wages or income garnished for any reason? Yes No
>
> \(6\) Failed or refused to pay any outstanding judgments? Yes No

\(e\) Have you or any company or depository institution with which you
are or were associated been involved in any 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, or revocation of license), agreement,
undertaking, consent, judgment, or order imposed by or entered into with
any of the following entities:

> \(1\) Any federal or state 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 been arrested for, charged with, indicted for, or
convicted of (including a conviction where the record was expunged), or
ever pleaded *nolo contendere* to, any criminal matter (other than minor
traffic violations)? Yes No

# (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, and, where relevant, including the:

-   Name and location of any institution, company, party, court,
    regulatory agency, or self-regulatory organization involved.

-   Nature of your association with any institution or company (for
    example, officer, director, organizer, principal shareholder, or
    owner).

```{=html}
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-   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.

-   Date of any relevant event.

-   Nature of any lawsuit, charge, or proceeding.

-   Jurisdiction in which any legal proceeding occurred.

-   Resolution or disposition of the matter.

**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.

  -----------------------------------------------------------------------
  **    **

  -----------------------------------------------------------------------

**FINANCIAL REPORT**

FINANCIAL STATEMENT AS OF      , \_\_\_\_\_\_

+----------------------+-----------+----------------------+-----------+
| ASSETS               |           | LIABILITIES AND NET  |           |
|                      |           | WORTH                |           |
+----------------------+-----------+----------------------+-----------+
| Cash on hand and in  | \$        | Accounts payable     | \$        |
|                      |           |                      |           |
| depository           |           | Notes payable and    |           |
| institutions         |           | other                |           |
|                      |           |                      |           |
| Marketable           |           | loans (Schedule F)   |           |
| securities           |           |                      |           |
|                      |           | Real estate          |           |
| (Schedule A)         |           | mortgages            |           |
|                      |           |                      |           |
| Notes receivable     |           | (Schedule C)         |           |
|                      |           |                      |           |
| (Schedule B)         |           | Other liabilities    |           |
|                      |           | (Schedule G)         |           |
| Real estate          |           |                      |           |
|                      |           | TOTAL LIABILITIES    |           |
| (Schedule C)         |           |                      |           |
|                      |           | Net worth (Total     |           |
| Proprietary          |           | assets less          |           |
| interests and        |           |                      |           |
|                      |           | total liabilities)   |           |
| other securities     |           |                      |           |
|                      |           |                      |           |
| (Schedule D)         |           |                      |           |
|                      |           |                      |           |
| Retirement funds and |           |                      |           |
| other                |           |                      |           |
|                      |           |                      |           |
| assets (Schedule E)  |           |                      |           |
+----------------------+-----------+----------------------+-----------+
| TOTAL ASSETS         | \$        | TOTAL LIABILITIES    | \$        |
|                      |           | AND                  |           |
|                      |           |                      |           |
|                      |           | NET WORTH            |           |
+----------------------+-----------+----------------------+-----------+

**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:

+--------------+-----------------+--------------------+-------+---+----+
| Name and     | Name and        | Description and    | Date  | C |    |
| Address of   | Address of      | Value of           |       | u |    |
|              |                 | Collateral         | Due   | r |    |
| Debtor or    | Creditor or     |                    |       | r |    |
| Obligor      | Obligee         |                    |       | e |    |
|              |                 |                    |       | n |    |
|              |                 |                    |       | t |    |
|              |                 |                    |       |   |    |
|              |                 |                    |       | A |    |
|              |                 |                    |       | m |    |
|              |                 |                    |       | o |    |
|              |                 |                    |       | u |    |
|              |                 |                    |       | n |    |
|              |                 |                    |       | t |    |
+--------------+-----------------+--------------------+-------+---+----+
|              |                 |                    |       |   |    |
+--------------+-----------------+--------------------+-------+---+----+
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
+--------------+-----------------+--------------------+-------+---+----+
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
+--------------+-----------------+--------------------+-------+---+----+
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
+--------------+-----------------+--------------------+-------+---+----+
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
+--------------+-----------------+--------------------+-------+---+----+
| TOTAL        |                 |                    |       | \ |    |
|              |                 |                    |       | $ |    |
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
|              |                 |                    |       |   |    |
+--------------+-----------------+--------------------+-------+---+----+

#### SUPPORTING SCHEDULES

  -----------------------------------------------------------------------
  Schedules must agree in total with the appropriate item contained in
  the Financial Statement on page 8 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                                                         \$      
  ------------------------------------------------------------- ---------

**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   | Owner of  | P   | Mort | Matu | C      | Cu    |
|                   | Property  | erc | gage | rity | urrent | rrent |
| Location          |           | ent | Ho   | Date | Market | B     |
|                   |           |     | lder |      | V      | alanc |
| (City and State)  |           | Own |      |      | alue\* | e\*\* |
|                   |           | er- |      |      |        |       |
|                   |           | s   |      |      |        |       |
|                   |           | hip |      |      |        |       |
+-------------------+-----------+-----+------+------+--------+-------+
|                   |           |     |      |      | \$     | \$    |
|                   |           |     |      |      |        |       |
+-------------------+-----------+-----+------+------+--------+-------+
|                   |           |     |      |      |        |       |
|                   |           |     |      |      |        |       |
+-------------------+-----------+-----+------+------+--------+-------+
|                   |           |     |      |      |        |       |
|                   |           |     |      |      |        |       |
+-------------------+-----------+-----+------+------+--------+-------+
|                   |           |     |      |      |        |       |
|                   |           |     |      |      |        |       |
+-------------------+-----------+-----+------+------+--------+-------+
|                   |           |     |      |      |        |       |
|                   |           |     |      |      |        |       |
+-------------------+-----------+-----+------+------+--------+-------+
| TOTAL             |           |     |      |      | \$     | \$    |
|                   |           |     |      |      |        |       |
+-------------------+-----------+-----+------+------+--------+-------+

\* Carry TOTAL forward to Assets - Real estate

\*\* Carry TOTAL forward to Liabilities - Real estate mortgages

**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   | Legal Form   | Nature of    | Percent | Current |
|                    |              | Business     |         | Value   |
| of Company         | of Company   |              | Ow      |         |
|                    |              |              | nership |         |
+--------------------+--------------+--------------+---------+---------+
|                    |              |              |         | \$      |
|                    |              |              |         |         |
+--------------------+--------------+--------------+---------+---------+
|                    |              |              |         |         |
+--------------------+--------------+--------------+---------+---------+
|                    |              |              |         |         |
+--------------------+--------------+--------------+---------+---------+
|                    |              |              |         |         |
+--------------------+--------------+--------------+---------+---------+
| TOTAL              |              |              |         | \$      |
|                    |              |              |         |         |
+--------------------+--------------+--------------+---------+---------+

##### 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        | Description and   | Maturity | Current |
| Creditor                   | Value of          | Date     | Balance |
|                            | Collateral        |          |         |
| and Loan Origination       |                   |          |         |
| Information                |                   |          |         |
+----------------------------+-------------------+----------+---------+
|                            |                   |          | \$      |
|                            |                   |          |         |
+----------------------------+-------------------+----------+---------+
|                            |                   |          |         |
+----------------------------+-------------------+----------+---------+
|                            |                   |          |         |
+----------------------------+-------------------+----------+---------+
|                            |                   |          |         |
+----------------------------+-------------------+----------+---------+
| TOTAL                      |                   |          | \$      |
|                            |                   |          |         |
+----------------------------+-------------------+----------+---------+

##### Schedule G - Other Liabilities

Include interest and taxes due and unpaid, other debts accrued, and
other liabilities.

  --------------------- ------------------------- ----------- ------------
  Payable To            Description               Maturity    Current
                                                  Date        Balance

                                                              \$      

                                                                   

                                                                   

                                                                   

                                                                   

  TOTAL                                                       \$      
  --------------------- ------------------------- ----------- ------------

**Cash Flow Statement\***

+-------------------+-----------+-----------+-----------+-----------+
| **[Sources of     | 20        | 20        | Projected | Projected |
| Ca                |           |           | Current   | Next      |
| sh]{.underline}** |           |           | Year      |           |
|                   |           |           | 20        | Year      |
|                   |           |           |           | 20        |
+-------------------+-----------+-----------+-----------+-----------+
| Salaries, wages,  | **\$      | **\$      | **\$      | **\$      |
| commissions, and  |      **   |      **   |      **   |      **   |
| other employment  |           |           |           |           |
| income            |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Rents, royalties, |           |           |           |           |
| and investments   |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Income from       | **     ** | **     ** | **     ** | **     ** |
| dividends and     |           |           |           |           |
| interest          |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Income and other  |           |           |           |           |
| distributions     |           |           |           |           |
| from partnerships |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Other sources\*\* | **     ** |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Total cash        |           |           |           |           |
| received          |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| **[Uses of        |           |           |           |           |
| Ca                |           |           |           |           |
| sh]{.underline}** |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Personal living   |           |           |           |           |
| expenses          |           |           |           |           |
|                   |           |           |           |           |
| (rent, household) |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Fixed             |           |           |           |           |
| obligations\*\*\* |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Income taxes      |           | **     ** |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Capital           |           |           |           |           |
| contributions to  |           |           |           |           |
| partnerships      |           |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| Other uses\*\*    |           | **     ** | **     ** | **     ** |
+-------------------+-----------+-----------+-----------+-----------+
| Total cash outlay | **     ** |           |           |           |
+-------------------+-----------+-----------+-----------+-----------+
| NET CASH FLOW     | **\$      | **\$      | **\$      | **\$      |
| (deficit)         |      **   |      **   |      **   |      **   |
+-------------------+-----------+-----------+-----------+-----------+

> \* Discuss any significant changes on a separate page.
>
> \*\* Itemize on a separate page any items amounting to 10 percent or
> more of total cash received or total cash outlay.
>
> \*\*\* 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.

**Privacy Act Notice**

## 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 -- that is, as a director, officer, employee, or principal shareholder. 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). The provision of requested information, including a Social Security Number, is voluntary. However, the failure to provide any requested information may result in denial, disapproval, or delay in the processing of an application or notice.

## 

Depending on the manner in which an appropriate federal banking agency
maintains solicited information, some or all of that information may be
subject to the Privacy Act of 1974, 5 U.S.C. § 552a. In such instances,
disclosures of covered information may be made to: (1) third parties to
complete background checks; (2) financial institutions for supervisory
purposes; (3) governmental, tribal, self-regulatory, or professional
organizations when information is relevant to either a known or
suspected violation of law or licensing standard or relevant and
necessary to the governmental or self-regulatory organization's
regulation or supervision of financial service providers; (4) the
Department of Justice, a court, an adjudicative body, a party in
litigation, or a witness when relevant and necessary to a legal or
administrative proceeding; (5) congressional offices when the
information is relevant to an inquiry initiated on behalf of its
provider; (6) an agency's contractors or agents; and (7) other third
parties when mandated or authorized by statute.

Additionally, while certain of the solicited information is exempt from
disclosure under the Freedom of Information Act because disclosure would
constitute a clearly unwarranted invasion of personal privacy, other
information is not exempt. Nonexempt information will ordinarily include
the names of individuals, the financial institutions that they propose
to serve, the statutory context in which information has been provided,
and prior bank-related employment and affiliation.

**CERTIFICATION**

*\*If a joint financial statement is being submitted, both parties
should complete the "Certification."*

I understand that the appropriate regulatory 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 [     ]{.underline} day of [     ]{.underline},
[     ]{.underline}.

  --------------------------------- -- -----------------------------------
                                       

  Signature                            Signature\*

                                            

  Print or type name                   Print or Type name

                                            

  Title (if applicable)                Title (if applicable)
  --------------------------------- -- -----------------------------------

[^1]: ^1^ A **company** seeking to acquire direct or indirect control of
    a bank or thrift should consult with the appropriate regulatory
    agency for filing instructions.

[^2]: Provide the foreign currency exchange rate and conversion date, if
    applicable.