FDIC 6822/02 (6-18) Page 1 of 7

OMB No. for FDIC 3064-0097; Expiration Date: July 31, 2024 

OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2024 

OMB No. for OCC 1557-0014; Expiration Date: January 31, 2024

Federal Deposit Insurance Corporation 

INTERAGENCY NOTICE OF CHANGE IN 

DIRECTOR OR SENIOR EXECUTIVE OFFICER

 

Public reporting burden for the collection of information in this Notice is estimated to average 2 hours per response, 

including the 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 (FDIC), 550 17th Street, NW, Washington, DC 20429; Secretary, Board of Governors of the Federal 

Reserve System (Board), 20th and C Streets, NW, Washington, DC 20551; or Chief National Bank Examiner, Office of 

the Comptroller of the Currency (OCC), 400 7th St. SW, Washington, DC 20219; and to the Office of Management and 

Budget (OMB), 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 

Who Must File 

This notice is used, as required by Section 32 of the Federal Deposit Insurance Act (Act) (12 U.S.C. § 1831i), by an 

insured depository institution or its holding company to notify the appropriate federal banking agency of a proposed 

change in the board of directors or senior executive officer of such institution or holding company. 

In general, this requirement is applicable to an insured depository institution or depository institution holding company 

that: 

■ is not in compliance with all minimum capital requirements applicable to such institution, as determined by the 

appropriate federal banking agency on the basis of such institution or holding company's most recent report of 

condition, report of examination or inspection; 

■ is in troubled condition; or 

■ the appropriate federal banking agency determines, in connection with its review of a capital restoration plan 

required under Section 38 of the Act (12 U.S.C. § 1831o) or otherwise, that such prior notice is appropriate. 

Preparation 

The insured depository institution or its holding company (filer) should complete this notice by providing a response to 

each of the questions and signing the Certification for each proposed individual. Information should be provided as of the 

notice's submission date. In addition, each individual must complete the Interagency Biographical and Financial Report. 

The filer and each individual are responsible for understanding the requirements and the accuracy of their statements. 

The completed form(s) should be sent to the appropriate federal banking agency. 

For additional information regarding the processing procedures and guidelines, and any supplemental information that 

may be required, refer to the appropriate Federal banking agency's procedural guidelines (for example, the OCC's Rules 

and Regulations (12 C.F.R. Part 5), the Comptroller's Licensing Manual, the FDIC's Rules and Regulations (12 C.F.R. 

Part 303), the Board's Regulations Y and LL (12 C.F.R. Part 225 and 12 C.F.R. Part 238, respectively), and relevant 

policy statements), contact the agency directly for specific instruction, or visit its website at www.occ.treas.gov, 

www.fdic.gov, or www.federalreserve.gov. 
FDIC 6822/02 (6-18) Page 2 of 7

OMB No. for FDIC 3064-0097; Expiration Date: July 31, 2024 

OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2024 

OMB No. for OCC 1557-0014; Expiration Date: January 31, 2024

Confidentiality 

In general, requests for confidential treatment of specific portions of the notice must be submitted in writing concurrently 

with the submission of the notice and must discuss the justification for the requested treatment. A notificant's reasons 

for requesting confidentiality should specifically demonstrate the harm (e.g., to its competitive position, invasion of 

privacy) that would result from public release of information (5 U.S.C. § 552). Information for which confidential 

treatment is requested should be (1) specifically identified in the public portion of the notice (by reference to the 

confidential section); (2) separately bound; and (3) labeled "Confidential." The notificant should follow the same 

procedure regarding a request for confidential treatment with regard to the subsequent filing of supplemental information 

to the notice. 

A notificant should contact the appropriate federal banking agency for specific instructions regarding requests for 

confidential treatment. The appropriate federal banking agency will determine whether the information submitted as 

confidential will be so regarded and will advise the notificant of any decision to make available to the public information 

labeled as "Confidential." 
FDIC 6822/02 (6-18) Page 3 of 7

OMB No. for FDIC 3064-0097; Expiration Date: July 31, 2024 

OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2024 

OMB No. for OCC 1557-0014; Expiration Date: January 31, 2024

PRIVACY ACT STATEMENT 

Purposes 

This form is used by an insured depository institution, a holding company, or an affected individual to notify the 

appropriate federal banking agency of a proposed change in the institution's board of directors or senior executive 

officers. If the institution is experiencing certain financial or supervisory difficulties, the appropriate federal banking 

agency must provide consent to the change. The federal banking agencies are the Board of Governors of the Federal 

Reserve System (Board), the Office of the Comptroller of the Currency (OCC) respectively, and the Federal Deposit 

Insurance Corporation (FDIC). This Privacy Act statement is made pursuant to the requirements of the Privacy Act of 

1974, 5. U.S.C. § 552a. 

Authority 

Section 32 of the Federal Deposit Insurance Act (12. U.S.C. § 1831i). 

Effects of Nondisclosure 

This form solicits information that enables the appropriate federal banking agency to evaluate each proposed addition of 

any individual to the board of directors or the employment of any individual as a senior executive officer and determine 

whether or not to disapprove it. Provision of the requested information is voluntary. However, failure to provide this 

information may result in disapproval of such a proposal or a determination that the legal requirement of prior notice has 

not been satisfied. 

Routine Uses for Board Filers 

The information you provide will be stored by the Board in the System of Records entitled "BGFRS-37: Electronic 

Applications." All or part of the information may be disclosed outside of the Board as follows: 

1. To the appropriate federal, state, local, foreign, or self-regulatory organization or agency responsible for 

investigating, prosecuting, enforcing, implementing, issuing, or carrying out a statute, rule, regulation, order, 

policy, or license if the information may be relevant to a potential violation of civil or criminal law, rule, regulation, 

order, policy, or license; 

2. To a federal agency in the executive, legislative, or judicial branch of government, or to a Federal Reserve Bank, 

in connection with the hiring, retaining, or assigning 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, 

the issuance of a license, grant, or other benefits by the receiving entity, or the lawful statutory, administrative, or 

investigative purpose of the receiving entity to the extent that the information is relevant and necessary to the 

receiving entity's decision on the matter; 

3. To a congressional office in response to an inquiry made by the congressional office at the request of the 

individual to whom the record pertains; 

4. To the Department of Justice, a court, an adjudicative body or administrative tribunal, a party in litigation, or a 

witness if the Board (or in the case of an Office of Inspector General (OIG) system, the OIG) determines, in its 

sole discretion, that the information is relevant and necessary to the matter; 

5. To contractors, agents, or others performing work on a contract, service, cooperative agreement, job, or other 

activity for the Board and who have a need to access the information in the performance of their duties or 

activities for the Board; 
FDIC 6822/02 (6-18) Page 4 of 7

OMB No. for FDIC 3064-0097; Expiration Date: July 31, 2024 

OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2024 

OMB No. for OCC 1557-0014; Expiration Date: January 31, 2024

PRIVACY ACT STATEMENT 

(continued)

6. To appropriate agencies, entities, and persons when (1) the Board suspects or confirms that the security or 

confidentiality of information in the system of records has been compromised; (2) the Board has determined that 

as a result of the suspected or confirmed compromise there is a risk of harm to economic or property interest, 

identity theft or fraud, or harm to the security or integrity of this system or other systems or programs (whether 

maintained by the Board or another agency or entity) that rely upon the compromised information; and (3) the 

disclosure is made to such agencies, entities, and persons who are reasonably necessary to assist in connection 

with the Board's efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy 

such harm; and 

7. To other bank and thrift regulatory agencies pursuant to explicit information sharing agreements for regulatory 

comment purposes. 

Routine Uses for FDIC Filers 

The information you provide will be stored by the FDIC in the System of Records entitled "FDIC 30-64-0002: Financial 

Institution Investigative and Enforcement Records." All or part of the information may be disclosed outside of the FDIC as 

follows: 

1. To federal, state, local, foreign, or self-regulatory authorities responsible for investigating or prosecuting a 

violation of, or for enforcing or implementing a statute, rule, regulation, or order issued, when the information 

indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and whether 

arising by general statute or particular program statute, or by regulation, rule, or order issued pursuant thereto; 

2. To a court, magistrate, or other administrative body in the course of presenting evidence, including disclosures to 

counsel or witnesses in the course of civil discovery, litigation, or settlement negotiations or in connection with 

criminal proceedings, when the FDIC is a party to the proceeding or has a significant interest in the proceeding, 

to the extent that the information is determined to be relevant and necessary; 

3. To a congressional office in response to an inquiry made by the congressional office at the request of the 

individual who is the subject of the record; 

4. To appropriate agencies, entities, and persons when (1) FDIC suspects or has confirmed that there has been a 

breach of the system of records; (2) FDIC has determined that as a result of the suspected or confirmed breach 

there is a risk of harm to individuals, FDIC (including its information systems, programs, and operations), the 

federal government, or national security; and (3) the disclosure made to such agencies, entities, and persons is 

reasonably necessary to assist in connection with FDIC's efforts to respond to the suspected or confirmed breach 

or to prevent, minimize, or remedy such harm; 

5. To another federal agency or federal entity, when FDIC determines that information from this system of records is 

reasonably necessary to assist the recipient agency or entity in (1) responding to a suspected or confirmed 

breach or (2) preventing, minimizing, or remedying the risk of harm to individuals, the recipient agency or entity 

(including its information systems, programs, and operations), the federal government, or national security, 

resulting from a suspected or confirmed breach; 

6. To federal, state, or foreign authorities in connection with hiring or retaining an individual, conducting a 

background security or suitability investigation, adjudication of liability, or eligibility for a license, contract, grant, 

or other benefit; 

7. To contractors, grantees, volunteers, and others performing or working on a contract, service, grant, cooperative 

agreement, or project for the FDIC, the OIG, or the federal government for use in carrying out their obligations 

under such contract, grant, agreement or project; 
FDIC 6822/02 (6-18) Page 5 of 7

OMB No. for FDIC 3064-0097; Expiration Date: July 31, 2024 

OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2024 

OMB No. for OCC 1557-0014; Expiration Date: January 31, 2024

PRIVACY ACT STATEMENT 

(continued)

8. To federal, state or foreign financial institutions supervisory authorities for regulatory or enforcement purposes, 

and 

9. To a financial institution affected by enforcement activities or reported criminal activities. 

Routine Uses for OCC Filers 

The information you provide may be stored by the OCC in the System of Records entitled "Notice of Proposed Changes 

in Employees, Officers and Directors Tracking System." Information maintained in this system may be disclosed to: 

1. A Section 5.51 entity, a Section 5.20(g)(2) entity, a part 163, subpart H entity, or a Section 1818(b) entity in 

connection with review and action on a notice filed by that entity; 

2. Third parties to the extent necessary to obtain information that is pertinent to the OCC's review and action on a 

notice received under any authority cited herein; 

3. Appropriate governmental or self-regulatory organizations when the OCC determines that the records are 

relevant and necessary to the governmental or self-regulatory organization's regulation or supervision of financial 

service providers, including the review of the qualifications and fitness of individuals who are or propose to 

become responsible for the business operations of such providers; 

4. An appropriate governmental, tribal, self-regulatory, or professional organization if the information is relevant to a 

known or suspected violation of a law or licensing standard within that organization's jurisdiction; 

5. The Department of Justice, a court, an adjudicative body, a party in litigation, or a witness if the OCC determines 

that the information is relevant and necessary to a proceeding in which the OCC, any OCC employee in his or 

her official capacity, any OCC employee in his or her individual capacity represented by the Department of 

Justice or the OCC, or the United States is a party or has an interest; 

6. A congressional office when the information is relevant to an inquiry made at the request of the individual about 

whom the record is maintained; 

7. A contractor or agent who needs to have access to this system of records to perform an assigned activity; 

8. Third parties when mandated or authorized by statute; or 

9. Appropriate agencies, entities, and persons when: (a) The Department suspects or has confirmed that the 

security or confidentiality of information in the system of records has been compromised; (b) the Department has 

determined that as a result of the suspected or confirmed compromise there is a risk of harm to economic or 

property interests, identity theft or fraud; or harm to the security or integrity of this system or other systems or 

programs (whether maintained by the Department or another agency or entity) that rely upon the compromised 

information; and (c) the disclosure made to such agencies, entities, and persons is reasonably necessary to 

assist in connection with the Department's efforts to respond to the suspected or confirmed compromise and 

prevent, minimize, or remedy such harm. 
FDIC 6822/02 (6-18) Page 6 of 7

OMB No. for FDIC 3064-0097; Expiration Date: July 31, 2024 

OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2024 

OMB No. for OCC 1557-0014; Expiration Date: January 31, 2024

Federal Deposit Insurance Corporation 

INTERAGENCY NOTICE OF CHANGE IN 

DIRECTOR OR SENIOR EXECUTIVE OFFICER

Details of Proposed Transaction:

Full Name of Individual

Notice to serve as a: Director

Senior Executive Officer

Title

Reason:

Name of Individual

To replace

To fill a new position

; or

Type of Filing: Prior Notice After-the-Fact Notice1 Waiver Previously Granted

Name of Insured Depository Institution or Holding Company

Street Address

City State ZIP Code

1. Describe the steps taken by the insured depository institution or holding company to investigate and satisfy itself as to 

 the competence, experience, character, and integrity of the subject individual. Summarize the individual's 

 qualifications for the proposed position. 

2. If this notice represents a proposal to serve as a senior executive officer of an insured depository institution or holding 

 company: 

 a. Describe the duties and responsibilities of the subject position or attach a position description, if applicable. 

 b. Discuss the proposed terms of employment of the subject individual and attach a copy of all pertinent documents, 

 including any applicable employment contract or compensation arrangement.2 

3. If this is an after-the-fact notice, identify the exception to the prior notice requirement upon which the notificant relies. If 

 no exception is available, discuss the reasons that prior notice was not given and what steps have been taken to avoid 

 future violations. 

1

 An after-the-fact notice may violate applicable notice requirements that could result in legal sanctions or resignation. 

2 The filing of any employment contract or compensation arrangement hereunder does not satisfy any other filings or 

requirements under other applicable laws or regulations.
FDIC 6822/02 (6-18) Page 7 of 7

OMB No. for FDIC 3064-0097; Expiration Date: July 31, 2024 

OMB No. for Federal Reserve 7100-0134; Expiration Date: May 31, 2024 

OMB No. for OCC 1557-0014; Expiration Date: January 31, 2024

CERTIFICATION 

I certify that the information provided in this notice has been carefully examined by me and is correct, complete, and 

made in good faith. The information included in the attached Interagency Biographical and Financial Report has been 

reviewed, and it is consistent with the information obtained by the insured depository institution or holding company. 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. 

Title of Authorized Representative

Name of Authorized Representative

Signature of Authorized Representative

Telephone Number

Email Address

Year , Month

day of

Day

Signed this .