Sec. 117.5. Information required in applications filed by individuals

(a) Name, address and relatives of applicant.

(1) Set forth the name, citizenship and business and residential addresses of the applicant, indicating the address to which communications from the Department of Financial Services should be sent.

(2) Set forth any other names by which the applicant has been known, and the circumstances thereof.

(3) Provide the name of applicant's spouse and all relatives of applicant, by blood or marriage, who, to applicant's knowledge, own or have agreed to acquire stock of the banking institution subject of the application.

(b) Birth date and place.

Provide the date and place of birth of the applicant.

(c) Former residences.

Provide the addresses of all former residences of the applicant during the last 10 years and the starting and ending dates of such residences.

(d) Education.

Provide the names and addresses of all high schools, colleges, universities, graduate programs, technical institutions and professional institutions attended by the applicant, the dates of attendance, any degrees received and the dates of such receipt.

(e) Professional licenses.

List all professional licenses or certificates held by applicant, stating the type of license or certificate, the date of issue, the issuing authority and the extent of applicant's activity thereunder.

(f) Employment.

(1) State the present principal occupation or employment of the applicant and the name, address and principal business of any enterprise, corporation or other entity in which such employment was carried on.

(2) List all occupations, positions, offices or employment of the applicant during the 10 years preceding the date of the application, giving the starting and ending dates of each and the name, address and principal business of any enterprise, corporation or other entity in which such employment was carried on.

(g) Other activities.

Provide the names of any civil, professional or fraternal associations of which applicant is or has been a member at any time during the five years preceding the date of the application, the dates of membership and a description of the activities carried on by such associations.

(h) Applicant's business.

Describe fully the applicant's business, including the name, jurisdiction of incorporation, percentage of ownership and lines of business of each corporate or other entity which:

(1) is owned or controlled by the applicant; or

(2) has accounted for 10 percent or more of the gross income of the applicant in either of the last two calendar or fiscal years of the applicant. The description of the business should include, but not be limited to, the following:

(i) a discussion of the general development of the business over the past two years;

(ii) a description of the principal services or products and any significant change therein during the past two years;

(iii) a list of each customer, or group of related customers, which accounts, either singly or in the aggregate, for 10 percent or more of the gross revenues of the business. Indicate whether such customers are directly or indirectly related to or affiliated with the applicant or its affiliates, and if so, how;

(iv) a list of the major suppliers of the business. Indicate whether such suppliers are directly or indirectly related to or affiliated with the applicant or its affiliates, and if so, how;

(v) a description of the source of availability of financing, if any, for the business. If any part consists of debt financing, provide the name and address of the lender(s) and describe the maturities and other terms of financing; and

(vi) a breakdown of the business' gross revenues for the past two years, showing the approximate amount of revenues, before income taxes and extraordinary items, attributable to each line of business which accounted for 10 percent or more of the revenues and/or losses of the business in either of the years covered.

(i) Convictions, bankruptcies, claims and proceedings.

(1) State whether or not the applicant has been convicted in any criminal proceeding (excluding traffic violations) or has been the subject of any bankruptcy or similar proceeding, and if so, provide the dates and description of any such conviction or proceeding, the court or tribunal in which the matter was heard and the ultimate disposition thereof.

(2) State whether or not any business with which the applicant has been associated as an officer, director, partner or 10 percent or more shareholder has been:

(i) the subject of any criminal indictment;

(ii) convicted in any criminal proceeding; or

(iii) the subject of any bankruptcy or similar proceeding, and if so, provide the date and description of any such proceeding, the court or tribunal in which the matter was heard and the ultimate disposition thereof.

(3) State whether or not the applicant or any business with which the applicant has been associated as an officer, director, partner or 10 percent or more shareholder is the subject of any:

(i) pending or threatened investigation, civil or criminal proceeding by any Federal, State, local or foreign governmental agency; or

(ii) pending or threatened claim.

Provide a description of the matters disclosed, the names of the agencies or parties involved, the courts or tribunals in which any such matters are pending, the status of the matters and the amounts (or reasonable estimates thereof) involved.

(j) Ownership or control of banking organizations.

State whether or not the applicant:

(1) directly or indirectly owns, either beneficially or of record, five percent or more of the equity interests in any banking organization; or

(2) directly or indirectly controls five percent or more of the equity interests in any banking organization.

If the answer to (1) or (2) is “yes”, identify the banking organization(s) involved, the nature and extent of such ownership and/or control, and the jurisdiction(s) in which the organization(s) are chartered.

(k) Financial statements of applicant.

Provide the following financial statements:

(1) Detailed statements of assets and liabilities of the applicant as of the last day of each of the three calendar or fiscal years of the applicant immediately preceding the date of the application, together with statements of income and changes in financial condition for such three calendar or fiscal years, prepared by an independent certified public accountant in accordance with the Statement on Standards for Accounting and Review Services, No. 1, Compilation and Review of Financial Statements, issued by the American Institute of Certified Public Accountants, as amended, or any statement issued in substitution therefor, and accompanied by review reports on such financial statements prepared by such accountant, stating that based on his review, he is not aware of any material modifications that should be made to such statements in order for them to be in conformity with generally accepted accounting principles, and stating in the report any exceptions thereto.

(2) A detailed statement of assets and liabilities of the applicant as of the last day of the calendar or fiscal quarter of the applicant immediately preceding the date of the application, together with statements of income and changes in financial condition for the period beginning on the first day of the calendar or fiscal year of the applicant then in progress and ending on such last day, prepared by an independent certified public accountant, and accompanied by a review report on such financial statements prepared by such accountant, stating that based on his review:

(i) nothing has come to his attention which would indicate that such statements were not prepared in accordance with accounting principles consistent with those principles applied in preparation of the annual financial statements provided pursuant to paragraph (1) of this subdivision; and

(ii) he is not aware of any material modifications that should be made to such statements in order for them to be in conformity with generally accepted accounting principles, and stating in the report any exceptions thereto.

(3) Detailed statements of assets and liabilities of the applicant as of:

(i) the last day of the calendar or fiscal year of the applicant immediately preceding the date of the application.

(ii) as of the last day of the calendar or fiscal quarter immediately preceding the date of the application, showing current estimated values, both reviewed by an independent certified public accountant and both accompanied by letters from such accountant stating the scope of his review.

(l) Financial statements of affiliates.

For all affiliates of the applicant referred to in section 117.3(c)(2) of this Supervisory Procedure and all other significant affiliates of the applicant, provide the annual and interim financial statements referred to in sections 117.4(g)(1) and (2) of this Supervisory Procedure and the annual reports referred to in section 117.4(g)(3) of this Supervisory Procedure.

(m) Banking and securities brokerage relationships.

(1) Provide a list of all banking organizations and securities brokerage firms with which:

(i) the applicant;

(ii) any affiliate of the applicant referred to in section 117.3(c)(2); and

(iii) any other significant affiliate of the applicant has or within the past five years has had a banking or customer relationship.

The list should summarize the nature of each such relationship and indicate the principal office of the banking organization or brokerage firm at which the relationship is or was maintained.

(2) Provide a letter addressed to each of the banking organizations or brokerage firms referred to in section 117.4(m)(1) of this Supervisory Procedure authorizing the addressee to provide the superintendent or his representatives with such financial or other information concerning the applicant and his affiliates as the superintendent or his representatives may request.

(n) Affiliations chart.

Provide a chart clearly presenting the identities of, and the interrelationships among, the applicant and all affiliates of the applicant. The chart should indicate:

(1) the percentage of voting securities of each person who controls, is controlled by, or is under common control with applicant;

(2) if control of any such person is maintained other than by the ownership or control of voting securities, the basis of such control; and

(3) the names of any other persons owning shares of any affiliates of the applicant.

The chart should also indicate, for each person specified in the chart, the type of organization (e.g., corporation, trust, partnership) involved and the state or other jurisdiction of domicile.

(o) References.

Provide the names and addresses of at least three personal references.