OMB No. 1530-0001

 

MINORITY BANK DEPOSIT PROGRAM

Financial Institution

Certification Form for Admission

I am applying for participation in the Minority Bank Deposit Program (MBDP) administered by the U.S. 

Department of the Treasury, Bureau of the Fiscal Service. 

1. Institution Name _____________________________________________________________________

 

 Address ____________________________________________________________________________

 

 City and State Zip Code___________________________________________ Zip Code ____________

2. Telephone No. Fax No. E-mail __________________________________________________________

3. Routing and Transit Number (ABA #) ____________________________________________________

4. Eligibility: Participation in the Minority Bank Deposit Program requires certification of eligibility by 

 completing the shares of ownership for each of the following categories: 

 a) Minority-Owned Bank or Savings and Loans: Yes No 

 If yes, please complete the number of shares below

Hispanic or Latino Ethnicity

Black or African American 

 American Indian or Alaska Native 

Native Hawaiian or Other Pacific Islander 

 Asian 

 White

 

b) Women-Owned Bank or Savings and Loans: Yes No 

If yes, please complete the number of shares below

 

Hispanic or Latino Ethnicity

Black or African American

 American Indian or Alaska Native 

Native Hawaiian or Other Pacific Islander 

 Asian 

 White

 c) Low-Income Credit Union designated by the National Credit Union Administration: Yes No 

5. Total Shares: _______________ Total Minority Shares: __________ 

6. Percentage of Minority Ownership: _____________

(If applying under the control criteria, in addition to completing items 1 through 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.) 
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 Bureau of the 

Fiscal Service (Fiscal Service) 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 Fiscal Service 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 noninterest bearing deposit from Fiscal Service, it shall return such funds to Fiscal Service and shall reimburse 

Fiscal Service 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 Fiscal Service. 

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. 

Signature ___________________________

Affix Bank or Notary Print Name __________________________

 Public seal 

Title________________________________

Not valid without seal

Date _______________________________

U.S. Department of the Treasury

Bureau of the Fiscal Service

Bank Policy and Oversight Division

401 14th Street, S.W., Room 317

Washington, DC 20227

 DEPARTMENT OF THE TREASURY

 BUREAU OF THE FISCAL SERVICE

FS FORM 3144 EDITION OF April 2016
Minority Bank Deposit Program

Eligibility Requirements

The eligibility requirements for participation in the Minority Bank Deposit Program (MBDP) are as follows:

1. Each member of a minority or women’s group having control or ownership of the institution is either a U.S. 

citizen or a U.S. resident.

2. Minority Banks and Stock Saving and Loans:

(a) Ownership: More than 50 percent of the outstanding stock must be owned by members of a

minority groups; or

(b) Control: A financial institution must be able to demonstrate that minorities hold, by means of 

voting trust and/or proxy agreements, enough shares so that when added to the shares owned by 

minorities, minorities control over 50 percent of the outstanding stock for voting purposes.

3. Women Banks: More than 50 percent of the outstanding stock must be owned by women, a majority of 

the Board of Directors must be women, and a significant percentage of senior management positions must 

be held by women.

4. Mutual Savings and Loans: A majority of the board of Directors must be members of minority groups.

5. Women Stock Savings and Loans: More than 50 percent of the outstanding stock must be owned by 

women, a majority of the Board of Directors must be women, and a significant percentage of senior 

management positions must be held by women.

6. Women Mutual Savings and Loans: A majority of the Board of Directors must be women and a significant

percentage of senior management positions must be held by women.

7. Low-income Credit Unions: All financial institutions must be designated low-income by the National 

Credit Union Administration (NCUA).

If a minority or women's certification includes stock held by corporations, partnerships, trusts, etc., the financial 

institution must certify that each such entity is minority owned or controlled, or in the case of women's 

institutions owned, controlled, and operated by women.

Paperwork Reduction Act and Privacy Act Statement

The information provided to the Department of the Treasury on this form is used solely to determine the 

financial institution's eligibility to participate in the Bureau of the Fiscal Service’s Minority Bank Deposit 

Program. Failure to respond in part or in total to this request will result in the financial institution's exclusion 

from consideration for, or expulsion from, the Minority Bank Deposit Program.

Burden Estimate Statement

The estimated average burden associated with this collection is 30 minutes per respondent or record keeper, 

depending on individual circumstances. Comments concerning the accuracy of this burden estimate and 

suggestions for reducing this burden should be directed to the Bureau of the Fiscal Service, Forms Management 

Officer, Parkersburg, WV 26106-1328. DO NOT SEND completed form to the above address; send to the 

address shown on page 2.