Attachment_4_-_OCC_Confidential_Financial_Disclosure_Report.pdf

Comptroller of the Currency Administrator of National Banks rev. Mar. 2012

OOOCCCCCC CCCOOONNNFFFIIIDDDEEENNNTTTIIIAAALLL FFFIIINNNAAANNNCCCIIIAAALLL DDDIIISSSCCCLLLOOOSSSUUURRREEE RRREEEPPPOOORRRTTT for Contractors of the Office of the Comptroller of the Currency Who Participate in Bank

Examinations and Other Bank Supervisory Activities

Contractor Last Name

First Name

Email Name

Home Address (Street) (City) (State) (Zip Code)

Position Title

Work Phone

Certification

I certify that all my responses on this OCC Confidential Financial Disclosure Report are true, complete, and correct to the best of my knowledge and belief. I understand that the filing of complete and accurate statements is mandatory for contractors and that the refusal to submit a statement when required or the submission of incomplete, false, or inaccurate information would be a violation of a legal requirement and could result in contract termination. I acknowledge that I am committed to observing the recusals listed on this report, including those listed in Part 7 of the report, except to the extent that these recusals have been amended, modified, or supplemented in writing by the appropriate ethics official.

Signature _______________________________________ Date _____________________

Part 1: Loans from National Banks or Federal Savings Associations

A. Loans from National Banks or Federal Savings Associations

Contractors will recuse themselves from any national bank or a federal savings association, which issued or currently holds their loan. In some cases, the ethics official may limit the recusal to the department or subsidiary that holds the loan.

A.1. Do you have one or more loans or extension of credits, other than a credit card, that are held by a national bank, a federal savings association, or a subsidiary of a national bank or a federal savings association? (Include loans issued jointly to you and any other person. Report only those loans of which a national bank or a federal savings association or a subsidiary of a national bank or a federal savings association is the owner or owner/servicer, as distinguished from loans for which the bank or savings association is only the servicer.)

YES NO

(If yes, describe in Appendix 1A at the end of the form. If no, skip to B.)

B. Spouse and Minor Child Loans and Extensions of Credit

(Note: Loans that are solely the obligation of a contractor’s spouse or minor child do not require the contractor to be recused from the issuing bank or savings association, unless the appropriate ethics official determines a recusal is necessary to avoid any appearance of a conflict of interest.)

B.1. Does your spouse or minor child have one or more loans or other extensions of credit from a national bank or a federal savings association or from a subsidiary of a national bank or a federal savings association (excluding credit cards and loans reported under A. above)?

(If yes, describe in Appendix 1B at the end of the form and answer B.2. If no, skip to C.)

C. Extensions of Credit from Affiliates of a National Bank or a Federal Savings Association

(Note: The term "affiliate" does not include subsidiaries of national banks or federal savings associations. See HELP for definition of "affiliate." The appropriate ethics official, may determine that an affiliate loan creates a real or apparent conflict with the performance of a contractor’s job duties.)

C.1. Are you or your spouse or minor child indebted to an affiliate of any national bank or federal savings association in amounts aggregating more than $25,000 (not including credit cards and loans secured by your primary residence, e.g., first mortgage or home equity loans)?

(If yes, describe in Appendix 1C at the end of the form. If no, skip to Part 2.)

Part 2: Financial Interests in Banks or Savings Associations

A. Ownership of Securities in Banks or Savings Associations

(Note: All OCC contractors and their spouses and minor children must report their interests in securities (e.g., stock and bonds) of the following: 1) commercial banks (both national and state), 2) savings associations (both federal and state), and 3) affiliates of banks or savings associations (e.g., bank holding companies). These reportable interests include financial interests that result when an OCC contractor, spouse, or minor child is the trustee or beneficiary of a trust that holds such securities.)

See HELP for a definition of the term "securities" and a list of other securities of banks or savings associations that must be reported, including securities that are held by partnerships, closely held corporations, or other entities in which the contractor or the contractor’s spouse or minor child has an ownership interest. Securities of a commercial company that owns a national bank or a federal savings association (e.g., General Electric, Nordstrom, Target) should be listed in Part 5 rather than this part.

A.1. Do you or your spouse or minor child directly or indirectly own securities in any commercial bank (national or state-chartered) or savings association (federal or state-chartered) or in any affiliate of a commercial bank or savings association (including a bank holding company)?

(If yes, describe in Appendix 2A at the end of the form. If no, skip to B.)

B. Financial Services Sector or Banking Sector Mutual Funds

(Note: All contractors, their spouses, and minor children must report their interest in mutual funds that have a stated policy of concentrating in the financial services sector (including the banking sector) or that has more than 25% of its assets invested in securities of banks or savings associations or their affiliates (which in most cases would also be financial services sector funds). A fund's prospectus will typically include a description of the fund's investment strategy or policy.)

B.1. Do you, your spouse, or minor children have an investment in a mutual fund or other collective investment fund or in a widely held pension or similar fund that has a stated policy of concentrating in the financial services sector or in the banking sector or that has more than 25% of its assets invested in securities of banks or savings associations or their affiliates?

(If yes, list in the table in Appendix 2B. If no, skip to C.)

C. Pension and Retirement Interests Resulting from an OCC Contractor or Spouse Working at a Bank or a Savings Association

(Note: When an OCC contractor or the contractor’s spouse participates in a pension or retirement plan from a bank or a savings association or from an affiliate of a bank or savings association (usually as a result of prior or current employment), a recusal is ordinarily required. Consult the OCC ethics official about the scope of the recusal.)

C.1. Do you or your spouse have any of the following arrangements with or continuing financial interests in a bank or a savings association or in an affiliate of a bank or a savings association (including a bank holding company) where you or your spouse have worked or plan to work in the future: a pension or retirement plan, including a defined benefit plan or defined contribution plan; an agreement or arrangement for future employment; a leave of absence; or a continuation of payment from a former employer?

(If yes, list in the table in Appendix 2C. If no, skip to Part 3.)

Part 3: Employment of Contractor or Family Members

The term "family member" includes a covered contractor’s spouse, father, mother, brother, sister, child, stepchild, grandparent, and grandchild; the father, mother, brother, sister, and grandparent of the contractor’s spouse; the spouse of the contractor’s father, mother, brother, sister, grandparent, child, step-child, and grandchild, and any other member of the contractor’s household.

(Note: A covered contractor generally must be recused from matters related to a national bank or a federal savings association or an affiliate where a family member of the contractor works or serves in some other capacity, unless an exception is granted by the appropriate ethics official. Covered contractors may also be recused on the basis of their own prior bank-related employment, especially if that employment occurred in the years immediately prior to contracting with the OCC. The appropriate ethics official may limit recusals or extend them to other affiliated or non-affiliated companies.)

1. During the past five years, have you served in any capacity with a commercial bank (national or state-chartered) or a savings association (federal or state-chartered) or an affiliate of a bank or savings association? Or do any of your family members currently serve in any capacity with one of these institutions?

(If yes, describe in Appendix 3. If no, skip to Part 4.)

Part 4: Outside Employment or Business Activity

(Note: Contractors are required to notify their OCC contact of all compensated or noncompensated outside employment or other business activity that they will be engaged in during the period when they are working for the OCC. The term "business activity" includes services performed with or without compensation for a corporation, company, firm, partnership or other business enterprise, nonprofit organization, or educational or other institution as an employee, owner, director, member, trustee, partner, advisor, or consultant. The term does not include uncompensated nonbusiness-related activities, such as membership or other participation in a nonprofit organization that does not involve making business decisions about that organization. Furthermore, unless there is a conflict or the appearance of a conflict of interest, contractors do not have to report any positions with religious, social, fraternal or political entities or those solely of an honorary nature.)

Since outside employment or business activities could raise the potential for an Organization Conflict of Interest (OCI), contractors must obtain prior written approval from their OCC contact and the concurrence of the appropriate ethics official before engaging in compensated or noncompensated outside employment or business activities while they are performing contracting services for the

OCC.

1. Are you employed (apart from your OCC contract work) or engaged in any other compensated or noncompensated business activity?

(If yes, describe in Appendix 4. If no, skip to Part 5.)

Part 5: Bankruptcy, Loan Default, or Debt Restructuring

A. Bankruptcy

A.1. Did you file for bankruptcy during the past three years?

YES NO

A.2. If you answered yes, provide the date and current status of the bankruptcy.

Enter date as MM/DD/YYYY:

Status:

A.3. If you answered yes, was there any debt owed to a national bank or a federal savings association discharged during the bankruptcy?

A.4. If you answered yes to A.3, provide the name and main office address of the bank or savings association.

Name and address:

B. Defaulted Loan

B.1. Did you have any loan(s) (including all extensions of credit in any form from any creditor, including commercial or consumer loans, auto loans, loans obtained from retailers or merchants, mortgages and credit cards) where interest and/or principal payments exceeded their due dates by more than 90 days during the past three years?

B.2. If you answered yes, provide the name and address of the lender and the current status of the loan.

Status:

C. Debt Restructuring

C.1. Did you engage in a debt restructuring transaction involving a national bank or a savings association, including a short sale (where the bank or savings association agreed to discount your loan balance) of your residential real property, during the past three years?

C.2. If you answered yes, provide the name and address of the bank or savings association office you dealt with and the date of the restructuring.

Enter date as MM/DD/YYYY:

Part 6: Other Conflicts of Interest

List other conflicts of interest or recusals not otherwise listed on this report, e.g., conflicts related to personal friendships or bank or savings association employment by a relative (uncle, cousin, etc.) not reported under Employment of Contractor or Family Members.

In addition, if a contractor or a contractor’s spouse or minor child owns securities of a commercial company that owns a national bank or a federal savings association, the contractor should list the ownership interest here and recuse himself or herself from the bank or savings association owned or operated by the company and from any particular matter that would affect his or her financial interests in the company. See the enclosed list of Commercial Holding Companies. Examples of such companies include General Electric, Nordstrom, and Target.

In the space below, list any other financial interests, relationships, or other circumstances that you believe could create a conflict of interest or the appearance of a conflict with the performance of your duties as an OCC contractor.

Name and address Nature of Conflict If you are observing a recusal, type "X"

Comments or Additional Entries

If you have any comments or entries that did not fit elsewhere on the form, enter them below.

Part 7: Attestation and Recusal

In signing on page 1 of this financial disclosure report, I acknowledge that I am committed to observing the recusals listed immediately below, except to the extent that these recusals have been amended, modified, or supplemented in writing by the appropriate ethics official. In addition, I attest that any national bank or federal savings association credit card held by myself (or by my spouse or minor children, if applicable) was sought and obtained on terms and conditions no more favorable than those offered to the general public.

Part 1: Unless otherwise advised by the ethics official, I will observe a recusal from any national bank or federal savings association to which I am indebted on a loan referenced in Part 1 or from the subsidiary or department that holds a loan referenced in Part 1. I will also observe a recusal with respect to the national bank or federal savings association holding a loan of my spouse or minor child referenced in Part 1B that remains my obligation under these rules.

Part 2A: I consider myself recused from any bank or savings association referenced in Part 2A as well as any affiliates (including holding company) of that bank or savings association.

Part 2B: I consider myself recused from any bank or savings association whose stock is held by a mutual fund listed in Part 2B, unless otherwise advised in writing by an appropriate ethics official.

Part 2C: I consider myself recused from any company and its affiliates which sponsor a defined benefit plan referenced in Part 2C.

Part 3: I consider myself recused from the bank or savings association or affiliate where a family member listed in Part 3 is employed or serves in some other capacity and will observe any recusal imposed by the ethics official for my own prior work at a bank or a savings association or an affiliate of a bank or a savings association

Part 4: I consider myself recused from performing any services under this contract which create the potential for an Organizational Conflict of Interest (OCI) and I will consult the OCI clause in the contract for additional guidance.

Parts 5 & 6: I will observe any recusals listed in Parts 5 and 6.

Finally, I will observe any other recusals specified by the appropriate ethics official.

Confidentiality

The OCC Financial Disclosure Report is confidential and is generally not subject to disclosure because it contains sensitive commercial and financial information, as well as personal privacy-protected information. This report and the information which it contains is, accordingly, exempt from being released to the public, under exemptions 3(a) and (b), 4 and 6 of the Freedom of Information Act (FOIA). Additional FOIA exemptions may apply to particular reports. Agency personnel shall not publicly release the OCC Financial Disclosure Reports or the information they contain, unless authorized by law.

AGENCY REVIEW

Signature of Ethics Official _______________________________________

Date ________________________________

Remarks:

----------------------------------------------- Appendices -------------------------------------

APPENDIX 1A - Loans and Extensions of Credit

Name of original lender (if applicable)

Complete name of current lender

Main office address (city and state)

Type of credit (car loan, etc.)

Date taken Amount Maturity date

APPENDIX 1B - Spouse and Minor Child Loans and Extensions of Credit

Complete name of bank or savings association

Main office address (city and state)

Type of credit (car loan, etc.)

Loans only:

Date taken

Amount Maturity date

B.2. Does each of your spouse's or minor child's loans meet ALL of the following requirements:

a. The loan is made on terms and conditions no more favorable than those offered to the general public;

b. You did not participate in the negotiation of the loan and you are not a party to the loan instrument as co-maker, endorser or guarantor; AND

c. The loan is supported solely by your spouse’s or minor child's own income or means?

(If no, list below the lender name and type of credit for any item that does not meet all three requirements. You will be recused from that bank or savings association.)

(If not applicable, skip to part C.)

(If yes, skip to C. No recusal is necessary, but you should advise your OCC contact before undertaking any contract service regarding a bank or a savings association where your spouse or minor child has a loan, so that you can avoid reviewing or taking any other specific action regarding that loan.)

Complete name of bank or savings association (from B.1.

above)

Type of credit (student loan, car loan, etc.)

APPENDIX 1C - Extensions of Credit from Affiliates of a National Bank or a Federal Savings Association

Borrower and relationship to you

Complete name of lender and affiliate

Main office address (city and state)

Type of credit (car loan, etc.)

Date taken

APPENDIX 2A - Ownership of Bank or Savings Association Securities

Owner (if not filer) and relationship to filer

Complete name of bank or savings association and affiliate

Main office address (city and state)

Nature of financial interest

Date and manner of acquisition (gift, etc.)

Approximate current market value

APPENDIX 2B - Financial Services Sector or Banking Sector Mutual Funds

Complete name of mutual or other fund

Number of shares Approximate current market value

Date acquired Manner of acquisition (by purchase, gift, inheritance, etc.)

APPENDIX 2C - Pension and Retirement Interests

Complete name of bank or savings association

Main office address Nature of arrangement or financial interest

Date acquired

APPENDIX 3 - Bank or Savings Association Employment of Contractor or Family Members

Name of person Relationship to you Complete name of bank or savings association and affiliate

Main office address (city and state)

Position and work location

Date(s) of employment

APPENDIX 4 - Outside Employment or Business Activity

Name of organization Address (city and state) Your position with organization Date(s) of employment