f1600-04 - Background Questionnaire for Contractor and Sub Personnel.pdf

Page 1 of 6FDIC 1600/04 (6-21)

OMB Number: 3064-0072 Expiration Date: 06/30/2028

Federal Deposit Insurance Corporation

BACKGROUND INVESTIGATION QUESTIONNAIRE

FOR CONTRACTOR AND SUBCONTRACTOR PERSONNEL

PRIVACY ACT STATEMENT

The FDIC is authorized to request this information from you by 12 U.S.C. §§ 1819, 1820(a), 1822(f); Executive Order 9397 as amended; and 12 C.F.R. Part 366. The purpose for collecting this information is to conduct a background investigation to determine whether you meet the required fitness and integrity standards for employment or performance under a contract with the FDIC. Furnishing the requested information is voluntary, but failure to provide the requested information in whole or in part may delay or prohibit any further consideration of you for employment or performance under a contract with the FDIC. The information you provide may be provided to appropriate Federal, state, local or foreign law enforcement authorities; to a court, administrative tribunal, or a party in litigation; to contractors, agents and other third parties as authorized by law; and in accordance with any of the other routine uses described in the FDIC Personnel Records (30-64-0015) System of Records available at www.fdic.gov/about/privacy. If you have questions or concerns about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at Privacy@fdic.gov.

ESTIMATED REPORTING BURDEN

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, Washington, D.C. 20429; and to the Office of Management and Budget, Paperwork Reduction Project (3064-0072), Washington, D.C. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Page down to access form 1600/04 http://www.fdic.gov/about/privacy mailto:Privacy@fdic.gov

Page 2 of 6FDIC 1600/04 (6-21)

Expiration Date: 06/30/2028

Federal Deposit Insurance Corporation

BACKGROUND INVESTIGATION QUESTIONNAIRE

FOR CONTRACTOR AND SUBCONTRACTOR PERSONNEL

INSTRUCTIONS: Complete each item on this form, as applicable.

SECTION I - GENERAL INFORMATION

This Background Investigation Questionnaire is being completed by: Contractor Personnel Subcontractor Personnel

1. Name First: Last: Middle:

2. Social Security Number 3. Sex

Male Female

4. Date of Birth

5. Place of Birth (City and State) 6. Are you a U.S. Citizen? 7. Country (If not U.S. Citizen) NoYes

8. Other Names Used (e.g. maiden name, names from former marriages, or aliases. Include the dates when used.) To add additional Name(s), see Appendix A.

Month/Year (From) Month/Year (To) Name

9. Residential Address (Start with current address and work backwards 10 years. Add as many lines as necessary.) To add additional Resident(s), see Appendix B.

Month/Year (From) Month/Year (To) Street Address (City, State, and Zip Code)

10. Employer's Name 11. Telephone

12. Employer's Address (Include City, State, and Zip Code) 13. Title/Position

14. Years with Employer

SECTION II - DISCLOSURE

Select one answer either Yes or No for each of the following questions. (If your response is Yes to any of the questions in Section II, provide a detailed explanation including dates, names, and the locations of the event(s) in question in the comments sections below.)

15. Have you ever been employed by the RTC/FDIC?

Yes No

(If Yes, provide the dates employed, agency, and location(s).)

16. Have you ever been convicted of a felony?

Yes No

(If Yes, provide the date(s), offense(s), law enforcement authority and/or court, city and state, and disposition of charges.)

17. Have you been removed from or prohibited from participating in the affairs of any FDIC-insured depository institution because of a federal banking agency action?

Yes No

(If Yes, provide a detailed description of the removal/prohibition.)

Page 3 of 6FDIC 1600/04 (6-21)

Expiration Date: 06/30/2028

12 CFR § 366.4 When is there a pattern or practice of defalcation?

(a) You have a pattern or practice of defalcation under § 366.3(c) when you, any person that owns or controls you, or any entity you own or control has a legal responsibility for the payment on at least two obligations that are:

(1) To one or more insured depository institutions;

(2) More than 90 days delinquent in the payment of principal, interest, or a combination thereof; and

(3) More than $50,000 each.

§ 366.6 How is my ownership or control determined?

(a) Your ownership or control is determined on a case-by-case basis. Your ownership or control depends on the specific facts of your situation and the particular industry and legal entity involved. You must provide documentation to us to use in determining your ownership or control.

(b) The interest of a spouse or other family member in the same organization is imputed to you in determining your ownership or control.

(c) The following are examples of when your ownership or control may or may not exist. These examples are not inclusive.

(1) You have control if you are the president or chief executive officer of an organization.

(2) You have ownership or control if you are a partner in a small law firm. You might not have ownership or control if you are a partner in a large national law firm.

(3) You have control if you are a general partner of a limited partnership. You have ownership or control if you have a limited partnership interest of 25 percent or more.

(4) You have ownership or control if you have the:

(i) Power to vote, directly or indirectly, 25% or more interest of any class of voting stock of a company;

(ii) Ability to direct in any manner the election of a majority of a company's directors or trustees; or

(iii) Ability to exercise a controlling influence over the company's management and policies.

18. Have you demonstrated a pattern or practice of defalcation regarding obligations? (See preceding instructions.)

Yes No

(If Yes, provide a detailed description of the pattern or practice of defalcation.)

12 CFR § 366.5 What causes a substantial loss to a federal deposit insurance fund?

You cause a substantial loss to the Deposit Insurance Fund (or any predecessor deposit insurance fund) under § 366.3(d) when you, or any person that owns or controls you, or any entity you own or control has:

(a) An obligation to us that is delinquent for 90 days or more and on which there is an outstanding balance of principal, interest, or a combination thereof of more than $50,000;

(b) An unpaid final judgment in our favor that is in excess of $50,000, regardless of whether it becomes discharged in whole or in part in a bankruptcy proceeding;

(c) A deficiency balance following foreclosure of collateral on an obligation owed to us that is in excess of $50,000, regardless of whether it becomes discharged in whole or in part in a bankruptcy proceeding; or

(d) A loss to us that is in excess of $50,000 that we report on IRS Form 1099--C, Information Reporting for Discharge of Indebtedness.

19. Have you caused a substantial loss to Federal deposit insurance funds?

(See preceding instructions.)

Yes No

(If Yes, provide a detailed description of the substantial loss to Federal deposit insurance funds.)

§ 366.14 (b) What information must I provide the FDIC?

A default on a material obligation occurs when a loan or advance with an outstanding balance of more than $50,000 is or was delinquent for 90 days or more.

20. Have you defaulted on a material obligation to any insured depository institution during the past 5 years? (See preceding instructions.)

Yes No

(If Yes, provide a detailed description of the default on a material obligation to any insured depository institution during the past 5 years.)

21. Have you ever been employed by a Financial Institution? (If Yes, complete the information below.) To add additional Financial Institutions, see Appendix C.

Yes No

Financial Institution (City and State) Month/Year (From) Month/Year (To)

Page 4 of 6FDIC 1600/04 (6-21)

Expiration Date: 06/30/2028

SECTION III - ELIGIBILITY CERTIFICATION

The purpose of the Eligibility Certification is to identify Prospective Contractor/Subcontractor Personnel who are not eligible to provide services to the Federal Deposit Insurance Corporation under the laws, regulations and policies governing contractor employee eligibility and based upon the Prospective Contractor's/Subcontractor's prior association or employment at a failed financial institution. Completion of the Eligibility Certification, without modification, is a prerequisite to any such employment.

The undersigned hereby certifies that all of the following statements are true, correct and complete when made and will be true as of the date of employment or commencement of the contract.

A. FDIC Employees. The Prospective Contractor/Subcontractor is not an FDIC employee, the spouse of an FDIC employee, or the minor child of an FDIC employee.

B. Delinquent Obligors. The Prospective Contractor/Subcontractor Employee does not have a Delinquent Obligation as defined above.

C. Officers or Directors of Failed Financial Institutions. The Prospective Contractor/Subcontractor has never been an officer or director of a Failed Financial Institution or of an affiliate of a Failed Financial Institution who (1) has participated in a material way in one or more transactions that caused a Substantial Loss to any such Failed Financial Institution; and (2) in connection with such Substantial Loss has been found by a court or administrative tribunal, or alleged in a judicial or administrative action brought by the FDIC or any federal or state governmental entity to have (i) violated any law, regulation or order issued by a federal or state banking agency; (ii) breached a written agreement with a federal or state banking agency or with a Failed Financial Institution; (iii) engaged in an unsafe or unsound practice in conducting the affairs of a Failed Financial Institution; or (iv) breached a fiduciary duty owed to a Failed Financial Institution.

D. Investigation of the Prospective Contractor Employee. The Prospective Contractor/Subcontractor is not under investigation for any conduct, either criminal or civil, related to his/her employment at a failed financial institution nor is the Prospective Contractor/ Subcontractor aware of any acts or circumstances that could lead to an investigation involving the Prospective Contractor/ Subcontractor. Should the Prospective Contractor/Subcontractor become aware of, or be notified that he/she is a target of an investigation after the commencement of the contract or employment with the Contractor, the Prospective Contractor/Subcontractor must notify the FDIC immediately and the FDIC reserves the right to request that the Contractor reassign the Prospective Contractor/ Subcontractor to other contracts not associated with providing services to the FDIC.

SECTION IV - AUTHORIZATION TO RELEASE INFORMATION (Carefully read the certification and authorization to release information below, then sign and date in ink.)

I certify that I have read and understood each question asked of me on this form, and that the information provided, including attachments to this form, is true and correct to the best of my knowledge, information, and belief as of the date of employment. I understand that anyone who knowingly or willfully makes false or fraudulent statements or representations in connection with disclosures or certifications herein may be subject to fines and/or imprisonment or both (18 U.S.C. § 1001 and § 1007). I agree to notify the FDIC immediately of any change in circumstances that would require disclosure hereunder.

I hereby authorize FDIC to conduct any investigation or inquiry necessary to verify the aforementioned information, the information provided in my resume or other personal data in order to verify my fitness and integrity to provide services for the Federal Deposit Insurance Corporation. The background investigation I am authorizing may require information contained herein and acquired during the investigation to be disclosed to third parties, including credit-reporting businesses and state and local licensing agencies. I hereby authorize and give my consent to such disclosures. This authorization will remain valid for the life of the contract or until termination of my employment or affiliation with the contractor, whichever is sooner.

Photocopies of this authorization that show my signature are as valid as the original signed by me. (Pursuant to section 604 of the Fair Credit Reporting Act, a separate notice in writing pertaining solely to obtaining a credit/consumer report will be provided to you. See 15 U.S.C. § 1681b(2)(A)).

22. Name 23. Signature (Sign in ink) 24. Date

Page 5 of 6FDIC 1600/04 (6-21)

Expiration Date: 06/30/2028

APPENDIX A

Question 8 continued. Other Names Used (e.g. maiden name, names from former marriages, or aliases.

Month/Year (From) Month/Year (To) Name

APPENDIX B

Question 9 continued. Residential Address (Start with current address and work backwards 10 years.

Month/Year (From) Month/Year (To) Street Address (City, State, and Zip Code)

APPENDIX C

Question 21 continued. Have you ever been employed by a Financial Institution? (If Yes, complete the information below.)

Financial Institution (City and State) Month/Year (From) Month/Year (To)

Page 6 of 6FDIC 1600/04 (6-21)

Expiration Date: 06/30/2028

DEFINITIONS

Contractor. Any individual or entity that has submitted an offer to the FDIC to perform services or has a contractual arrangement with the FDIC to perform services.

Delinquent Obligation. Any debt or duty to pay money to the FDIC in excess of $50,000 (in the aggregate for all such debts or duties) that is more than 60 days delinquent, or any other failure to comply with the terms and conditions of a written agreement with the FDIC that continues for more than sixty (60) days following notice. A Delinquent Obligation does not include any debt that has been settled, or any debt that has been sold or transferred by the FDIC, or any debt for which the FDIC has reported forgiveness of debt through the issuance of an IRS form 1099, nor any debt discharged in bankruptcy.

Failed Financial Institution. Any bank or savings association that has been under the conservatorship or receivership of the FDIC or of the Resolution Trust Corporation. It includes any entity owned and controlled by such a bank or savings association.

FDIC. FDIC means the Federal Deposit Insurance Corporation, whether acting in its corporate capacity or as conservator or receiver of a Failed Financial Institution.

Prospective Contractor/Subcontractor. Any individual that has or intends to provide services to the FDIC as a Contractor/ Subcontractor employee for a Contractor that has a contractual arrangement with the FDIC.

Substantial Loss. i) any debt or duty to pay money to the FDIC or a failed financial institution that has an outstanding balance of more than $50,000 and that is more than 90 days past due; (ii) an unpaid final judgment of more than $50,000 regardless of whether it is forgiven in a bankruptcy proceeding; (iii) a deficiency balance following a foreclosure sale of more than $50,000 regardless of whether it is forgiven in a bankruptcy proceeding; or (iv) any loss of more than $50,000 reported on an IRS Form 1099-C (Information Reporting for Discharge of Indebtedness).

FDIC 1600/04 (6-21)

FDIC 1600/04 (6-21)

OMB Number: 3064-0072 Expiration Date: 06/30/2028 OMB Number: 3064-0072 Expiration Date: 06/30/2028

FDIC 1600/04 (6-21)

FDIC 1600/04 (6-21)

OMB Number: 3064-0072 Expiration Date: 06/30/2028 OMB Number: 3064-0072 Expiration Date: 06/30/2028

FDIC 1600/04 (6-21)

FDIC 1600/04 (6-21)

OMB Number: 3064-0072 Expiration Date: 06/30/2028 OMB Number: 3064-0072 Expiration Date: 06/30/2028

FDIC 1600/04 (6-21)

FDIC 1600/04 (6-21)

OMB Number: 3064-0072 Expiration Date: 06/30/2028 OMB Number: 3064-0072 Expiration Date: 06/30/2028

FDIC 1600/04 (6-21)

FDIC 1600/04 (6-21)

OMB Number: 3064-0072 Expiration Date: 06/30/2028 OMB Number: 3064-0072 Expiration Date: 06/30/2028

FDIC 1600/04 (6-21)

FDIC 1600/04 (6-21)

OMB Number: 3064-0072 Expiration Date: 06/30/2028 OMB Number: 3064-0072 Expiration Date: 06/30/2028 Federal Deposit Insurance Corporation

BACKGROUND INVESTIGATION QUESTIONNAIRE

FOR CONTRACTOR AND SUBCONTRACTOR PERSONNEL

Federal Deposit Insurance Corporation

BACKGROUND INVESTIGATION QUESTIONNAIRE

FOR CONTRACTOR AND SUBCONTRACTOR PERSONNEL

PRIVACY ACT STATEMENT

PRIVACY ACT STATEMENT

The FDIC is authorized to request this information from you by 12 U.S.C. §§ 1819, 1820(a), 1822(f); Executive Order 9397 as amended; and 12 C.F.R. Part 366. The purpose for collecting this information is to conduct a background investigation to determine whether you meet the required fitness and integrity standards for employment or performance under a contract with the FDIC. Furnishing the requested information is voluntary, but failure to provide the requested information in whole or in part may delay or prohibit any further consideration of you for employment or performance under a contract with the FDIC. The information you provide may be provided to appropriate Federal, state, local or foreign law enforcement authorities; to a court, administrative tribunal, or a party in litigation; to contractors, agents and other third parties as authorized by law; and in accordance with any of the other routine uses described in the FDIC Personnel Records (30-64-0015) System of Records available at www.fdic.gov/about/privacy. If you have questions or concerns about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at Privacy@fdic.gov.

The FDIC is authorized to request this information from you by 12 U.S.C. §§ 1819, 1820(a), 1822(f); Executive Order 9397 as amended; and 12 C.F.R. Part 366. The purpose for collecting this information is to conduct a background investigation to determine whether you meet the required fitness and integrity standards for employment or performance under a contract with the FDIC. Furnishing the requested information is voluntary, but failure to provide the requested information in whole or in part may delay or prohibit any further consideration of you for employment or performance under a contract with the FDIC. The information you provide may be provided to appropriate Federal, state, local or foreign law enforcement authorities; to a court, administrative tribunal, or a party in litigation; to contractors, agents and other third parties as authorized by law; and in accordance with any of the other routine uses described in the FDIC Personnel Records (30-64-0015) System of Records available at www.fdic.gov/about/privacy. If you have questions or concerns about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at Privacy@fdic.gov.

ESTIMATED REPORTING BURDEN

PRIVACY ACT STATEMENT

ESTIMATED REPORTING BURDEN

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, Washington, D.C. 20429; and to the Office of Management and Budget, Paperwork Reduction Project (3064-0072), Washington, D.C. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, Washington, D.C. 20429; and to the Office of Management and Budget, Paperwork Reduction Project (3064-0072), Washington, D.C. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Federal Deposit Insurance Corporation

BACKGROUND INVESTIGATION QUESTIONNAIRE

FOR CONTRACTOR AND SUBCONTRACTOR PERSONNEL

Federal Deposit Insurance Corporation

BACKGROUND INVESTIGATION QUESTIONNAIRE

FOR CONTRACTOR AND SUBCONTRACTOR PERSONNEL

INSTRUCTIONS: Complete each item on this form, as applicable.

INSTRUCTIONS: Complete each item on this form, as applicable.

SECTION I - GENERAL INFORMATION

SECTION 1 - GENERAL INFORMATION

This Background Investigation Questionnaire is being completed by:

This Background Investigation Questionnaire is being completed by:

1. Name

3. Sex

3. Sex. Radio button option to choose sex either Male or Female. Use arrow keys to select one.

6. Are you a U.S. Citizen?

6. Are you a U.S. Citizen? Use arrow keys to select one.

8. Other Names Used (e.g. maiden name, names from former marriages, or aliases. Include the dates when used.) To add additional Name(s), see Appendix A.

8. Other Names Used (e.g. maiden name, names from former marriages, or aliases. Include the dates when used.)

8. Month/Year (From) (Header) Month/Year (From)

8. Month/Year (To) (Header) Month/Year (To)

8. Name (Header) Name

9. Residential Address (Start with current address and work backwards 10 years. Add as many lines as necessary.) To add additional Resident(s), see Appendix B.

9. Residential Address (Start with current address and work backwards 10 years. Add as many lines as necessary.)

9. Month/Year (From) (Header) Month/Year (From)

9. Month/Year (To) (Header) Month/Year (To)

9. Street Address (City, State, and Zip Code) (Header) Street Address (City, State, and Zip Code)

SECTION II - DISCLOSURE

SECTION 2 - DISCLOSURE

Select one answer either Yes or No for each of the following questions. (If your response is Yes to any of the questions in Section II, provide a detailed explanation including dates, names, and the locations of the event(s) in question in the comments sections below.)

Select one answer either Yes or No for each of the following questions. (If your response is Yes to any of the questions in Section 2, provide a detailed explanation including dates, names, and the locations of the event(s) in question in the comments sections below.)

15. Have you ever been employed by the RTC/FDIC?

15. Have you ever been employed by the RTC/FDIC? Tab to select Yes or No. (If Yes, provide the dates employed, agency, and location(s).)

16. Have you ever been convicted of a felony?

16. Have you ever been convicted of a felony? Tab to select Yes or No. If Yes, provide the date(s), offense(s), law enforcement authority and/or court, city and state, and disposition of charges.

17. Have you been removed from or prohibited from participating in the affairs of any FDIC-insured depository institution because of a federal banking agency action?

17. Have you been removed from or prohibited from participating in the affairs of any FDIC-insured depository institution because of a federal banking agency action? Tab to select Yes or No. If Yes, provide a detailed description of the removal/prohibition.

12 CFR § 366.4 When is there a pattern or practice of defalcation?

(a) You have a pattern or practice of defalcation under § 366.3(c) when you, any person that owns or controls you, or any entity you own or control has a legal responsibility for the payment on at least two obligations that are:

(1) To one or more insured depository institutions;

(2) More than 90 days delinquent in the payment of principal, interest, or a combination thereof; and

(3) More than $50,000 each.

12 CFR § 366.4 When is there a pattern or practice of defalcation?

(a) You have a pattern or practice of defalcation under § 366.3(c) when you, any person that owns or controls you, or any entity you own or control has a legal responsibility for the payment on at least two obligations that are:

(1) To one or more insured depository institutions;

(2) More than 90 days delinquent in the payment of principal, interest, or a combination thereof; and

(3) More than $50,000 each.

§ 366.6 How is my ownership or control determined?

(a) Your ownership or control is determined on a case-by-case basis. Your ownership or control depends on the specific facts of your situation and the particular industry and legal entity involved. You must provide documentation to us to use in determining your ownership or control.

(b) The interest of a spouse or other family member in the same organization is imputed to you in determining your ownership or control.

(c) The following are examples of when your ownership or control may or may not exist. These examples are not inclusive.

(1) You have control if you are the president or chief executive officer of an organization.

(2) You have ownership or control if you are a partner in a small law firm. You might not have ownership or control if you are a partner in a large national law firm.

(3) You have control if you are a general partner of a limited partnership. You have ownership or control if you have a limited partnership interest of 25 percent or more.

(4) You have ownership or control if you have the:

(i) Power to vote, directly or indirectly, 25% or more interest of any class of voting stock of a company;

(ii) Ability to direct in any manner the election of a majority of a company's directors or trustees; or

(iii) Ability to exercise a controlling influence over the company's management and policies.

§ 366.6 How is my ownership or control determined?

(a) Your ownership or control is determined on a case-by-case basis. Your ownership or control depends on the specific facts of your situation and the particular industry and legal entity involved. You must provide documentation to us to use in determining your ownership or control.

(b) The interest of a spouse or other family member in the same organization is imputed to you in determining your ownership or control.

(c) The following are examples of when your ownership or control may or may not exist. These examples are not inclusive.

(1) You have control if you are the president or chief executive officer of an organization.

(2) You have ownership or control if you are a partner in a small law firm. You might not have ownership or control if you are a partner in a large national law firm.

(3) You have control if you are a general partner of a limited partnership. You have ownership or control if you have a limited partnership interest of 25 percent or more.

(4) You have ownership or control if you have the:

(i) Power to vote, directly or indirectly, 25% or more interest of any class of voting stock of a company;

(ii) Ability to direct in any manner the election of a majority of a company's directors or trustees; or

(iii) Ability to exercise a controlling influence over the company's management and policies.

18. Have you demonstrated a pattern or practice of defalcation regarding obligations? (See preceding instructions.)

18. Have you demonstrated a pattern or practice of defalcation regarding obligations? Tab to select Yes or No. (See preceding instructions.)

Question 18. 12 CFR § 366.4 When is there a pattern or practice of defalcation?

(a) You have a pattern or practice of defalcation under § 366.3(c) when you, any person that owns or controls you, or any entity you own or control has a legal responsibility for the payment on at least two obligations that are:

(1) To one or more insured depository institutions;

(2) More than 90 days delinquent in the payment of principal, interest, or a combination thereof; and

(3) More than $50,000 each.

12 CFR § 366.5 What causes a substantial loss to a federal deposit insurance fund?

You cause a substantial loss to the Deposit Insurance Fund (or any predecessor deposit insurance fund) under § 366.3(d) when you, or any person that owns or controls you, or any entity you own or control has:

(a) An obligation to us that is delinquent for 90 days or more and on which there is an outstanding balance of principal, interest, or a combination thereof of more than $50,000;

(b) An unpaid final judgment in our favor that is in excess of $50,000, regardless of whether it becomes discharged in whole or in part in a bankruptcy proceeding;

(c) A deficiency balance following foreclosure of collateral on an obligation owed to us that is in excess of $50,000, regardless of whether it becomes discharged in whole or in part in a bankruptcy proceeding; or

(d) A loss to us that is in excess of $50,000 that we report on IRS Form 1099--C, Information Reporting for Discharge of Indebtedness.

19. Have you caused a substantial loss to Federal deposit insurance funds?

(See preceding instructions.)

19. Have you caused a substantial loss to Federal deposit insurance funds? Tab to select Yes or No. (See preceding instructions.)

Question 19. 12 CFR § 366.5 What causes a substantial loss to a federal deposit insurance fund?

You cause a substantial loss to the Deposit Insurance Fund (or any predecessor deposit insurance fund) under § 366.3(d) when you, or any person that owns or controls you, or any entity you own or control has:

(a) An obligation to us that is delinquent for 90 days or more and on which there is an outstanding balance of principal, interest, or a combination thereof of more than $50,000;

(b) An unpaid final judgment in our favor that is in excess of $50,000, regardless of whether it becomes discharged in whole or in part in a bankruptcy proceeding;

(c) A deficiency balance following foreclosure of collateral on an obligation owed to us that is in excess of $50,000, regardless of whether it becomes discharged in whole or in part in a bankruptcy proceeding; or

(d) A loss to us that is in excess of $50,000 that we report on IRS Form 1099--C, Information Reporting for Discharge of Indebtedness.

§ 366.14 (b) What information must I provide the FDIC?

A default on a material obligation occurs when a loan or advance with an outstanding balance of more than $50,000 is or was delinquent for 90 days or more.

20. Have you defaulted on a material obligation to any insured depository institution during the past 5 years? (See preceding instructions.)

20. Have you defaulted on a material obligation to any insured depository institution during the past 5 years? Tab to select Yes or No. (See preceding instructions.)

Question 20. § 366.14 (b) What information must I provide the FDIC?

A default on a material obligation occurs when a loan or advance with an outstanding balance of more than $50,000 is or was delinquent for 90 days or more.

21. Have you ever been employed by a Financial Institution? (If Yes, complete the information below.) To add additional Financial Institutions, see Appendix C.

21. Have you ever been employed by a Financial Institution? Tab to select Yes or No. (If Yes, complete the information below.)

21. Financial Institution (City and State) (Header) Financial Institution (City and State)

21. Month/Year (From) (Header) Month/Year (From)

21. Month/Year (To) (Header) Month/Year (To)

SECTION III - ELIGIBILITY CERTIFICATION

SECTION 3 - ELIGIBILITY CERTIFICATION

The purpose of the Eligibility Certification is to identify Prospective Contractor/Subcontractor Personnel who are not eligible to provide services to the Federal Deposit Insurance Corporation under the laws, regulations and policies governing contractor employee eligibility and based upon the Prospective Contractor's/Subcontractor's prior association or employment at a failed financial institution. Completion of the Eligibility Certification, without modification, is a prerequisite to any such employment.

The undersigned hereby certifies that all of the following statements are true, correct and complete when made and will be true as of the date of employment or commencement of the contract.

A. FDIC Employees. The Prospective Contractor/Subcontractor is not an FDIC employee, the spouse of an FDIC employee, or the minor child of an FDIC employee.

B. Delinquent Obligors. The Prospective Contractor/Subcontractor Employee does not have a Delinquent Obligation as defined above.

C. Officers or Directors of Failed Financial Institutions. The Prospective Contractor/Subcontractor has never been an officer or director of a Failed Financial Institution or of an affiliate of a Failed Financial Institution who (1) has participated in a material way in one or more transactions that caused a Substantial Loss to any such Failed Financial Institution; and (2) in connection with such Substantial Loss has been found by a court or administrative tribunal, or alleged in a judicial or administrative action brought by the FDIC or any federal or state governmental entity to have (i) violated any law, regulation or order issued by a federal or state banking agency; (ii) breached a written agreement with a federal or state banking agency or with a Failed Financial Institution; (iii) engaged in an unsafe or unsound practice in conducting the affairs of a Failed Financial Institution; or (iv) breached a fiduciary duty owed to a Failed Financial Institution.

D. Investigation of the Prospective Contractor Employee. The Prospective Contractor/Subcontractor is not under investigation for any conduct, either criminal or civil, related to his/her employment at a failed financial institution nor is the Prospective Contractor/Subcontractor aware of any acts or circumstances that could lead to an investigation involving the Prospective Contractor/Subcontractor. Should the Prospective Contractor/Subcontractor become aware of, or be notified that he/she is a target of an investigation after the commencement of the contract or employment with the Contractor, the Prospective Contractor/Subcontractor must notify the FDIC immediately and the FDIC reserves the right to request that the Contractor reassign the Prospective Contractor/Subcontractor to other contracts not associated with providing services to the FDIC.

The purpose of the Eligibility Certification is to identify Prospective Contractor/Subcontractor Personnel who are not eligible to provide services to the Federal Deposit Insurance Corporation under the laws, regulations and policies governing contractor employee eligibility and based upon the Prospective Contractor's/Subcontractor's prior association or employment at a failed financial institution. Completion of the Eligibility Certification, without modification, is a prerequisite to any such employment.

The undersigned hereby certifies that all of the following statements are true, correct and complete when made and will be true as of the date of employment or commencement of the contract.

A. FDIC Employees. The Prospective Contractor/Subcontractor is not an FDIC employee, the spouse of an FDIC employee, or the minor child of an FDIC employee.

B. Delinquent Obligors. The Prospective Contractor/Subcontractor Employee does not have a Delinquent Obligation as defined above.

C. Officers or Directors of Failed Financial Institutions. The Prospective Contractor/Subcontractor has never been an officer or director of a Failed Financial Institution or of an affiliate of a Failed Financial Institution who (1) has participated in a material way in one or more transactions that caused a Substantial Loss to any such Failed Financial Institution; and (2) in connection with such Substantial Loss has been found by a court or administrative tribunal, or alleged in a judicial or administrative action brought by the FDIC or any federal or state governmental entity to have (i) violated any law, regulation or order issued by a federal or state banking agency; (ii) breached a written agreement with a federal or state banking agency or with a Failed Financial Institution; (iii) engaged in an unsafe or unsound practice in conducting the affairs of a Failed Financial Institution; or (iv) breached a fiduciary duty owed to a Failed Financial Institution.

D. Investigation of the Prospective Contractor Employee. The Prospective Contractor/Subcontractor is not under investigation for any conduct, either criminal or civil, related to his/her employment at a failed financial institution nor is the Prospective Contractor/Subcontractor aware of any acts or circumstances that could lead to an investigation involving the Prospective Contractor/Subcontractor. Should the Prospective Contractor/Subcontractor become aware of, or be notified that he/she is a target of an investigation after the commencement of the contract or employment with the Contractor, the Prospective Contractor/Subcontractor must notify the FDIC immediately and the FDIC reserves the right to request that the Contractor reassign the Prospective Contractor/Subcontractor to other contracts not associated with providing services to the FDIC.

SECTION IV - AUTHORIZATION TO RELEASE INFORMATION (Carefully read the certification and authorization to release information below, then sign and date in ink.)

Section 4 - Authorization to Release Information (Carefully read the certification and authorization to release information below, then sign and date in ink.)

APPENDIX A

SECTION 2 - DISCLOSURE

Question 8 continued. Other Names Used (e.g. maiden name, names from former marriages, or aliases.

8. Other Names Used (e.g. maiden name, names from former marriages, or aliases. Include the dates when used.)

8. Month/Year (From) (Header) Month/Year (From)

8. Month/Year (To) (Header) Month/Year (To)

8. Name (Header) Name

APPENDIX B

SECTION 2 - DISCLOSURE

Question 9 continued. Residential Address (Start with current address and work backwards 10 years.

9. Residential Address (Start with current address and work backwards 10 years. Add as many lines as necessary.)

9. Month/Year (From) (Header) Month/Year (From)

9. Month/Year (To) (Header) Month/Year (To)

9. Street Address (City, State, and Zip Code) (Header) Street Address (City, State, and Zip Code)

APPENDIX C

SECTION 2 - DISCLOSURE

Question 21 continued. Have you ever been employed by a Financial Institution? (If Yes, complete the information below.)

21. Have you ever been employed by a Financial Institution? Tab to select Yes or No. (If Yes, complete the information below.)

21. Financial Institution (City and State) (Header) Financial Institution (City and State)

21. Month/Year (From) (Header) Month/Year (From)

21. Month/Year (To) (Header) Month/Year (To)

DEFINITIONS

DEFINITIONS

Contractor. Any individual or entity that has submitted an offer to the FDIC to perform services or has a contractual arrangement with the FDIC to perform services.

Delinquent Obligation. Any debt or duty to pay money to the FDIC in excess of $50,000 (in the aggregate for all such debts or duties) that is more than 60 days delinquent, or any other failure to comply with the terms and conditions of a written agreement with the FDIC that continues for more than sixty (60) days following notice. A Delinquent Obligation does not include any debt that has been settled, or any debt that has been sold or transferred by the FDIC, or any debt for which the FDIC has reported forgiveness of debt through the issuance of an IRS form 1099, nor any debt discharged in bankruptcy.

Failed Financial Institution. Any bank or savings association that has been under the conservatorship or receivership of the FDIC or of the Resolution Trust Corporation. It includes any entity owned and controlled by such a bank or savings association.

FDIC. FDIC means the Federal Deposit Insurance Corporation, whether acting in its corporate capacity or as conservator or receiver of a Failed Financial Institution.

Prospective Contractor/Subcontractor. Any individual that has or intends to provide services to the FDIC as a Contractor/Subcontractor employee for a Contractor that has a contractual arrangement with the FDIC.

Substantial Loss. i) any debt or duty to pay money to the FDIC or a failed financial institution that has an outstanding balance of more than $50,000 and that is more than 90 days past due; (ii) an unpaid final judgment of more than $50,000 regardless of whether it is forgiven in a bankruptcy proceeding; (iii) a deficiency balance following a foreclosure sale of more than $50,000 regardless of whether it is forgiven in a bankruptcy proceeding; or (iv) any loss of more than $50,000 reported on an IRS Form 1099-C (Information Reporting for Discharge of Indebtedness).

Contractor. Any individual or entity that has submitted an offer to the FDIC to perform services or has a contractual arrangement with the FDIC to perform services.

Delinquent Obligation. Any debt or duty to pay money to the FDIC in excess of $50,000 (in the aggregate for all such debts or duties) that is more than 60 days delinquent, or any other failure to comply with the terms and conditions of a written agreement with the FDIC that continues for more than sixty (60) days following notice. A Delinquent Obligation does not include any debt that has been settled, or any debt that has been sold or transferred by the FDIC, or any debt for which the FDIC has reported forgiveness of debt through the issuance of an IRS form 1099, nor any debt discharged in bankruptcy.

Failed Financial Institution. Any bank or savings association that has been under the conservatorship or receivership of the FDIC or of the Resolution Trust Corporation. It includes any entity owned and controlled by such a bank or savings association.

FDIC. FDIC means the Federal Deposit Insurance Corporation, whether acting in its corporate capacity or as conservator or receiver of a Failed Financial Institution.

Prospective Contractor/Subcontractor. Any individual that has or intends to provide services to the FDIC as a Contractor/Subcontractor employee for a Contractor that has a contractual arrangement with the FDIC.

Substantial Loss. i) any debt or duty to pay money to the FDIC or a failed financial institution that has an outstanding balance of more than $50,000 and that is more than 90 days past due; (ii) an unpaid final judgment of more than $50,000 regardless of whether it is forgiven in a bankruptcy proceeding; (iii) a deficiency balance following a foreclosure sale of more than $50,000 regardless of whether it is forgiven in a bankruptcy proceeding; or (iv) any loss of more than $50,000 reported on an IRS Form 1099-C (Information Reporting for Discharge of Indebtedness).

Todd Hamme 3/14/17

DOA/SEPS

FDIC

1600/04 Background Investigation Questionnaire for Contractor and Subcontractor Personnel For questions on this form, email Forms@fdic.gov.

9/1/2021 (AA)