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: