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Minority Bank Deposit Program (MBDP)


Minority Bank Deposit Program Financial Institution Certification Form for Admission

OMB No. 1530-0001

NOTE: Only recertifications will be accepted by electronic form. Incomplete forms may be rejected.

If you are new financial institution, please send the form PDF document by mail.

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.

Institution Name
(required)
Address:
(required)
City/State/Zip:
(required)
Telephone No.:
(required)
Fax No.:
E-mail:
(required)
Routing & Transit Number (ABA #):
(required)

Certification of Eligibility:  Please complete the number of shares of ownership for each of the following categories:

Minority-Owned Bank or Savings and Loans
(If yes, please complete the number of shares below)
Hispanic or Latino Ethnicity:
American Indian or Alaska Native:
Black or African-American:
Asian
Native Hawaiian or Other Pacific Islander:
Women-Owned Bank or Savings and Loans
(If yes, please complete the number of shares below)
Hispanic or Latino Ethnicity:
American Indian or Alaska Native:
Black or African-American:
Asian:
Native Hawaiian or Other Pacific Islander:
White:
Low-Income Credit Union designated by NCUA
Total Shares:
(required)
Minority Code
Total Minority Shares:
(required)
Percentage of Minority Ownership:
(required)

If applying under the control criteria, in addition to completing items 1-6, 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:

Department of the Treasury
Bureau of the Fiscal Service



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