Online Recertification Application

OMB No. 1530-0001

Note: only recertifications will be accepted by electronic form; incomplete forms may be rejected. If you are a new financial institution, please fill out and send the Certification Form PDF by mail, as detailed on the Getting Started page.

Recertification Form

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. Fields marked with an asterisk(*) are required.

Institutional Name

Address

City

State

Zip

Phone Number

Fax Number

Email Address

Routing & Transit Number (ABA #)

Certification of Eligibility

If you select "Yes" to any of these, add the number of shares per ethnicity below.

Minority-owned Bank or Savings or Loans Yes No

Hispanic or Latino Ethnicity

American Indian or Alaska Native

Black or African-American

Asian

Native Hawaiian or Other Pacific Islander

White

Woman-owned Bank or Savings or Loans Yes No

Hispanic or Latino Ethnicity

American Indian or Alaska Native

Black or African-American

Asian

Native Hawaiian or Other Pacific Islander

White

Low-Income Credit Unit designated by NCUA Yes No

Total Shares

Minority Code

Total Minority Shares

Percentage of Minority Ownership

If applying under the control criteria, in addition to completing the above fields, 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. Please mail this documentation to:

Federal Reserve Bank of St. Louis
Attn: Treasury Support Center Analysts
PO Box 442
St. Louis, MO 63166

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. Also if the institution receives funds, including but not limited to the Treasury Tax & Loan non-interest bearing deposit from Fiscal Service, it shall return such funds to Fiscal Service and shall reimburse the bureau 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.

I hereby certify that the above named official(s) are authorized to release collateral:

Name

Title

Date

Last modified 08/30/19