Appendix A.  

_______________________

(Covered Entity Name)

April 15, 20_____

Certification of Compliance with New York State Department of Financial Services Cybersecurity Regulations

The Board of Directors or a Senior Officer(s) of the Covered Entity certifies:

(1) The Board of Directors (or name of Senior Officer(s)) has reviewed documents, reports, certifications and opinions of such officers, employees, representatives, outside vendors and other individuals or entities as necessary;

(2) To the best of the (Board of Directors) or (name of Senior Officer(s)) knowledge, the Cybersecurity Program of (name of Covered Entity) as of ____________ (date of the Board Resolution or Senior Officer(s) Compliance Finding) for the year ended _____ (year for which Board Resolution or Compliance Finding is provided) complies with Part _____.

Signed by the Chairperson of the Board of Directors or Senior Officer(s)

(Name) _______________________ Date: ______________________

[DFS Portal Filing Instructions]