"Biographical Information and Financial Report" - Georgia (United States)

Biographical Information and Financial Report is a legal document that was released by the Georgia Department of Banking and Finance - a government authority operating within Georgia (United States).

Form Details:

  • Released on December 20, 2013;
  • The latest edition currently provided by the Georgia Department of Banking and Finance;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Georgia Department of Banking and Finance.

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BIOGRAPHICAL INFORMATION AND FINANCIAL REPORT
GENERAL INFORMATION AND INSTRUCTIONS
1
This Biographical Information and Financial Report (report) is used by individuals
associated
with a Georgia Merchant Acquirer Limited Purpose Bank (MALPB) application or related filing
to the Department of Banking and Finance (Department). This report is not a stand-alone
document.
Preparation
Use of this report format is not mandatory. If an alternative format is used, it must provide all
requested information, including the certification. All questions must be answered with complete
and accurate information that is subject to verification. If the answer is “none,” “not applicable,”
or “unknown,” so state. Answers of “unknown” or “yes” should be explained.
The questions are not intended to limit the presentation nor are the questions intended to
duplicate information supplied on another form or in an exhibit. For example, a cross-reference
to the information is acceptable. Any cross-reference must be made to a specific cite or location
in the documents, so the information can be located easily. Use additional sheets as necessary.
If the report is not complete, the Department may either request additional information or return
the filing. If you are a foreign national or a United States citizen who currently resides in a
foreign country, additional information may be necessary.
Financial statements from individuals must have “as of” dates of not more than 90 days prior to
the date the financial report is submitted. All amounts in this report must be based on current
2
market value in United States dollars
and agree with any totals in the supplementary
schedules. In addition to the sample financial schedules, you may wish to provide
supplementary schedules for other items on the financial statement. If the sample financial
statement is used, an answer is required to each item. If you submit an alternative Financial
Report format, the information must respond to each request for information contained in the
sample Financial Report.
In addition, the Department specifically reserves the right to require up to five years of financial
data from any acquiring person as well as the filing of additional information and/or statements,
such as a federal income tax return or a current appraisal to support an asset's value.
Each individual must report promptly any material change in the biographical information or
financial condition that occurs during the review period for the filing.
An entity, other than a natural person, seeking to acquire direct or indirect control of an MALPB should
1
consult with the Department for filing instructions.
Provide the foreign currency exchange rate and conversion date, if applicable.
2
(Revised December 20, 2013)
BIOGRAPHICAL INFORMATION AND FINANCIAL REPORT
GENERAL INFORMATION AND INSTRUCTIONS
1
This Biographical Information and Financial Report (report) is used by individuals
associated
with a Georgia Merchant Acquirer Limited Purpose Bank (MALPB) application or related filing
to the Department of Banking and Finance (Department). This report is not a stand-alone
document.
Preparation
Use of this report format is not mandatory. If an alternative format is used, it must provide all
requested information, including the certification. All questions must be answered with complete
and accurate information that is subject to verification. If the answer is “none,” “not applicable,”
or “unknown,” so state. Answers of “unknown” or “yes” should be explained.
The questions are not intended to limit the presentation nor are the questions intended to
duplicate information supplied on another form or in an exhibit. For example, a cross-reference
to the information is acceptable. Any cross-reference must be made to a specific cite or location
in the documents, so the information can be located easily. Use additional sheets as necessary.
If the report is not complete, the Department may either request additional information or return
the filing. If you are a foreign national or a United States citizen who currently resides in a
foreign country, additional information may be necessary.
Financial statements from individuals must have “as of” dates of not more than 90 days prior to
the date the financial report is submitted. All amounts in this report must be based on current
2
market value in United States dollars
and agree with any totals in the supplementary
schedules. In addition to the sample financial schedules, you may wish to provide
supplementary schedules for other items on the financial statement. If the sample financial
statement is used, an answer is required to each item. If you submit an alternative Financial
Report format, the information must respond to each request for information contained in the
sample Financial Report.
In addition, the Department specifically reserves the right to require up to five years of financial
data from any acquiring person as well as the filing of additional information and/or statements,
such as a federal income tax return or a current appraisal to support an asset's value.
Each individual must report promptly any material change in the biographical information or
financial condition that occurs during the review period for the filing.
An entity, other than a natural person, seeking to acquire direct or indirect control of an MALPB should
1
consult with the Department for filing instructions.
Provide the foreign currency exchange rate and conversion date, if applicable.
2
(Revised December 20, 2013)
This report is filed with respect to:
Name of Subject Company, Location:_____________________________________________
Type of Filing
Position
MALPB Charter
Organizer
Change in Control
Director
Senior Executive Officer
Change in Senior Executive Officer or Director
Principal Shareholder
Eligible Organization
Other_________________
Other_________________
BIOGRAPHICAL INFORMATION
1. Personal Information
(a) Name
Last
First
(Middle-no initials)
(b) Residence _______________________________________________________________
(Street Address)
(City)
(State/Province)
(ZIP Code)
(Country)
(c) If at residence less than five years, list addresses and dates occupied for past five years.
Date From / Date To Number and Street
City
State/Province ZIP Code Country
(d) Date of Birth: Month: _______________ Day:
Year: _________
(e) Place of Birth:
(City)
(State/Province)
(Country)
(f) United States Social Security Number:
(g) Citizenship
Country
(Date, if Naturalized)
1
(h) If not a United States citizen, provide:
Passport Number:
Home Country Identification Number:
Immigration File Number:
Father's full name:
Mother's full name, including maiden name:
(i) Telephone and fax numbers where you may be reached during business hours and e-mail
address:
(Area Code, Telephone Number, including Country Code if outside the U.S.)
(Fax Number)
E-mail Address
(j) List other names you used and the period of time you used them (for example, your
maiden name, name by a former marriage, former name, alias, or nickname). If the other
name is your maiden name, put “nee” in front of it.
2. Employment Record
(a) List employment in reverse chronological order for the last five years. The list should
include the beginning and ending dates of employment, the employer’s name and location
(city, state/province, country), nature of business, title or position, nature of duties, and
reason for leaving.
(b) Have you ever been dismissed or asked to resign from any past employment, including a
less than honorable discharge from military service? Yes____ No ____
If “yes,” provide the employer’s name, address, and telephone number; title or position;
date of discharge; and explanation.
2
3. Education and Professional Credentials
(a) List each diploma or degree from high schools, colleges, universities, or other schools.
School's Name/Location
From
To
Degree
(b) List each professional license or similar certificate you now hold or have held (for
example, Attorney, Physician, CPA, NASD or SEC registration).
License
Issuing Authority
Date Issued
Status
Expiration
4. Business and Merchant Acquirer Affiliations
(a) List any company with which you are associated, providing the company name, location,
nature or type of business, position held or relationship to the company, ownership
percentage, and beginning date of the relationship.
(b) List the name of any merchant acquiring entity or affiliate with which you are or were
associated. Also list the location, nature of activity, position held or relationship,
ownership percentage, and beginning and ending dates of the relationship.
3
(c) Are you now or in the process of being considered for an executive officer or director
position at another merchant acquiring company and/or affiliate?
Yes____ No ____
If yes, provide the name of the entity and the position.
5. Legal and Related Matters
(a) Have you been involved in any of the following filings where the filing was denied,
disapproved, withdrawn, or otherwise returned without favorable action by a federal or
state regulatory authority or a self-regulatory organization:
(1) An MALPB charter or license application, a depository institution application, a
federal deposit insurance application, or a holding company application, in which
you were listed as an organizer, executive officer, director or a person that would
own or control (either individually or as a member of a group) 10 percent or more
of any class of voting securities or other voting equity interest of the institution, or
similar position? Yes____ No ____
(2) A merger application in which you were listed as an executive officer, director or
similar position? Yes____ No ____
(3) A notice of change in executive officer or director, or similar form, in which you
were listed as an executive officer, director, or similar position?
Yes____ No ____
(4) A notice of change in control or a similar form, in which you were listed (either
individually or as a member of a group) as an acquirer or transferee?
Yes____ No ____
(5) Any other application, notice, or other regulatory or administrative request which
was filed with a federal or state regulatory authority or a self-regulatory
organization in which you were listed in some capacity? Yes____ No ____
(b) Have you or any merchant acquiring institution, merchant acquiring institution holding
company, and/or affiliate with which you are or were associated been subject to any
supervisory agreement, enforcement action, civil money penalty, prohibition or removal
order, or other supervisory or administrative action taken or imposed by any federal or state
regulatory authority or other governmental entity? Yes____ No ____
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