Form FR Y-3 FR Y-3 Application for Prior Approval to Become a Bank Holding

FR Y-3
OMB No. 7100–0121
Approval expires
April 2008

APPLICATION
to the
BOARD OF GOVERNORS OF THE FEDERAL RESERVE SYSTEM
(‘‘Board’’)

Corporate Title of Applicant

Street

City

State

Zip Code

(Type of organization, such as corporation, partnership, business trust, association, or trust)

Hereby applies to the Board pursuant to:
(1) Section 3(a)(1) of the Bank Holding Company Act of 1956, as amended, (‘‘BHC Act’’—
12 U.S.C. 1842), under ‘‘Procedures for other bank acquisition proposals’’ as described in
section 225.15 of Regulation Y;
(2) Section 3(a)(3) of the BHC Act, under ‘‘Procedures for other bank acquisition proposals’’ as
described in section 225.15 of Regulation Y; or
(3) Section 3(a)(5) of the BHC Act, under ‘‘Procedures for other bank acquisition proposals’’ as
described in section 225.15 of Regulation Y.
for prior approval of the acquisition of direct or indirect ownership, control, or power to vote at least
(

%) of a class of voting shares or otherwise to control:

number

Corporate Title of Bank or Bank Holding Company

Street

City

State

Zip Code

Name, title, address, telephone number and facsimile number of person(s) to whom inquiries concerning this application may
be directed:

Please check:

Draft

Final
Signature of Chief Executive Officer or Designee

Signed this

day of

,

.
Typed Name and Title

Public Reporting Burden for this collection of information for applications
filed pursuant to section 3(a)(1) of the BHC Act are estimated to average
49 hours per response while applications filed pursuant to section 3(a)(3)
or section 3(a)(5) of the BHC Act are estimated to average 59.5 hours per
response, including the time to gather and maintain data in the required
form, to review instructions and to complete the information collection.
The Federal Reserve may not conduct or sponsor, and an organization is

not required to respond to, a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this
burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to: Secretary, Board of
Governors of the Federal Reserve System, 20th and C Streets, N.W.,
Washington, D.C. 20551; and to the Office of Management and Budget,
Paperwork Reduction Project (7100-0121), Washington, D.C. 20503.

Insert A
Does Applicant request confidential treatment for any portion of this submission?
Yes
In accordance with page __ of the instructions, a letter
justifying the request for confidential treatment is included.
The information for which confidential treatment is being
sought is separately bound and labeled “CONFIDENTIAL.”
No
Certification
I certify that the information contained in this application has been examined
carefully by me and is true, correct, and complete, and is current as of the date of
this submission to the best of my knowledge and belief. I acknowledge that any
misrepresentation or omission of a material fact constitutes fraud in the inducement
and may subject me to legal sanctions provided by 18 USC 1001 and 1007.
I also certify, with respect to any information pertaining to an individual and
submitted to the Board in (or in connection with) this application, that the applicant
has the authority, on behalf of the individual, to provide such information to the
Board and to consent or to object to public release of such information. I certify
that the applicant and the involved individual consent to public release of any such
information, except to the extent set forth in a written request by the applicant or
the individual, submitted in accordance with the Instructions to this form and the
Board's Rules Regarding Availability of Information (12 CFR Part 261), requesting
confidential treatment for the information.
I acknowledge that approval of this application is in the discretion of the Board of
Governors of the Federal Reserve System (the “Federal Reserve”). Actions or
communications, whether oral, written, or electronic, by the Federal Reserve or its
employees in connection with this filing, including approval if granted, do not
constitute a contract, either express or implied, or any other obligation binding
upon the agency, the United States or any other entity of the United States, or any
officer or employee of the United States. Such actions or communications will not
affect the ability of the Federal Reserve to exercise its supervisory, regulatory, or
examination powers under applicable laws and regulations. I further acknowledge
that the foregoing may not be waived or modified by any employee or agency of
the Federal Reserve or of the United States.