Utah Department of Financial Institutions



STATE OF UTAH

DEPARTMENT OF FINANCIAL INSTITUTIONS

324 South State Street, Suite 201, SLC, UT 84111

Mailing Address: PO Box 146800, Salt Lake City, UT 84114-6800

(801) 538-8830

7-1-703 - application for registration of financial institution holding company

| |initial registration | |annual renewal registration |

|Date: | |Date Received: (DFI USE ONLY): | |

Financial Institution Holding Company (Registering Entity):

|Name: | |

|Address: | |

|City: | |State: | |Zip: | |

| |

|Company Website: | |Fiscal Year End: | |

|Date Incorporated: | |

Utah Chartered Financial Institution(s) Owned or Controlled by the Registering Entity:

|Institution Name(s): | |

| | |

|Type (check one): | |Commercial Bank | |Industrial Bank |

Contact Person at Registering Entity:

|Name: | |

|Title: | |Phone: | |

|Email: | |

|Address: | |

|City: | |State: | |Zip: | |

Holding Company Type (check one):

| |Immediate (First Level) Holding Company | |Intermediate (Mid Level) Holding Company |

| | | | |

| |Ultimate (Top Level) Holding Company | |Other Control Party Under §7-1-103(5) |

Additional Information and Required Attachments

1. Mark and attach, as applicable:

| |Audited Financial Statement | |Unaudited Financial Statement |

| |

| |Company Annual Report | |SEC Filing |

| |

| |No financial statements are produced for this entity |

2. Identify independent auditor:

| |N/A, or: |

|Name: | |Opinion Type: |(e.g., unqualified, qualified) |

|Engaged Since: | |

3. Nature of internal audit coverage provided at the top tier registering entity:

| |None (N/A) | |In-house internal audit exists at this level |

| |

| |Internal audit provided by a parent company | |Outsourced Internal Audit |

4. Number of employees claimed by the top tier registering entity (on a global, consolidated basis):

| |

5. If applicable, provide current credit ratings assigned by any Nationally Recognized Statistical Rating Organizations (e.g., S&P, Moody’s Fitch) for the registering entity:

| |N/A, or: |

|Rating Agency name |Short Term Debt Rating |Long Term Debt Rating |Outlook |As of Date |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

6. Identify all banks, regardless of charter type, over which the registering entity has control (expand as needed):

| |N/A, or: |

| |

|Bank Name |Chartering Body |Primary Regulator |If US bank, FDIC |Total Assets as of Most|Under Formal |

| | | |Certificate Number |Recent |Enforcement Action? |

| | | | |Call Report | |

| | | | | | |

| | | | | | |

7. Complete the organizational chart below illustrating ownership from the bank to the ultimate top tier parent. Include consolidated total assets for each entity as of most recent fiscal year-end (expand as needed).

Note: If the ownership chain above the bank is not conducive to the direct line format provided below, please attach a separate legal entity-based organizational chart illustrating the registering entity’s place in the complete ownership chain above the bank. Remember to include consolidated total assets for each entity in the chain, as of most recent fiscal year-end.

|[ Top Tier Holding Company Name ] & [ Consol. Total Assets $ ] |

| | |

|[ Mid Tier Holding Company, or “N/A” ] & [ Consol. Total Assets $ ] |

| | |

|[ Mid Tier Holding Company, or “N/A” ] & [ Consol. Total Assets $ ] |

| | |

|[ Utah Bank Name ] |

8. Attach a certificate of good standing from the state in which in which the registering entity is incorporated.

9. If changed since the prior registration, attach a copy of the registering entity’s most recent Articles of Incorporation.

10. Attach a list of the names and the principal occupation of the registering entity’s executive officers and directors.

11. Attach a list of individuals owning 20% or more of the outstanding voting stock in the registering entity.

12. Attach a list of entities owning 10% or more of the outstanding voting stock in the registering entity.

13. Number of *shares authorized in the Articles of Incorporation: .

*Note: If more than one class of shares are authorized, please provide breakdown on a separate page. Please identify which class of shares have voting rights.

14. Number of *shares issued and outstanding as of July 1 of current year: .

*Note: If more than one class of shares are issued, please provide breakdown on a separate page. Please

identify which class of shares have voting rights.

Affidavit

I, __________________________________________, of the above-named corporation, do hereby certify

(Name of Authorized Person)

that the foregoing information, attachments, and statements are true and correct.

Dated this day of , 20 .

By Title

(Signature)

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