Form IL 581-0034 Officers/Directors Affidavit - Illinois

Form IL581-0034 is a Illinois Department of Financial and Professional Regulation form also known as the "Officers/directors Affidavit". The latest edition of the form was released in April 1, 2006 and is available for digital filing.

Download an up-to-date Form IL581-0034 in PDF-format down below or look it up on the Illinois Department of Financial and Professional Regulation Forms website.

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OFFICERS/DIRECTORS AFFIDAVIT
IMPORTANT NOTICE
This State agency is requesting disclosure of information that is necessary to determine compliance with Sections 3-
4(a), 3-9 (a) and 3-11(a) of the Illinois Savings and Loan Act of 1985. Disclosure of this information is
MANDATORY. Failure to provide the information could result in a fine under the provisions of Section 7-7(a) of the
Illinois Savings and Loan Act of 1985. This form has been approved by the State Forms Management Center.
FILING INSTRUCTIONS
This form is to be executed by directors and/or officers. If director only, strike “officer” and “directors” under 1. If
officer only, strike “director” and “members” under 1. If director and officer, the wording under 1 should suffice.
STATE OF ILLINOIS
)
) ss
COUNTY OF ___________ )
The undersigned, being duly sworn on oath state as follows:
1.
I was duly elected a (director/officer) of _______________________________________, at a
(members/directors) meeting held on _____________________________.
2.
I have not declared bankruptcy or been convicted of a criminal offense involving dishonesty or a
breach of trust or convicted for a violation of any laws of the United States or of any foreign state
relating to savings and loan associations.
3.
I am not an officer or director of another state or federal mutual savings and loan association to which
the Illinois Savings and Loan Act of 1985 applies.
4.
I have attached hereto a true and correct statement setting forth details as to the present and for the past
five (5) years, my business and professional resume, my business affiliations and my dealings with
any financial institution. Business affiliations means any office held, does not include compilation of
loans, checking accounts or savings accounts in various financial institutions.
Under penalty of perjury, I have placed my hand and seal this ______day of _______________, 20_____, at
_____________________, Illinois.
____________________________________
director/officer
Signed and sworn to before me this _______
day of _______________________, 20____.
____________________________________
Notary Public
IL 581-0034 (04-06)
OFFICERS/DIRECTORS AFFIDAVIT
IMPORTANT NOTICE
This State agency is requesting disclosure of information that is necessary to determine compliance with Sections 3-
4(a), 3-9 (a) and 3-11(a) of the Illinois Savings and Loan Act of 1985. Disclosure of this information is
MANDATORY. Failure to provide the information could result in a fine under the provisions of Section 7-7(a) of the
Illinois Savings and Loan Act of 1985. This form has been approved by the State Forms Management Center.
FILING INSTRUCTIONS
This form is to be executed by directors and/or officers. If director only, strike “officer” and “directors” under 1. If
officer only, strike “director” and “members” under 1. If director and officer, the wording under 1 should suffice.
STATE OF ILLINOIS
)
) ss
COUNTY OF ___________ )
The undersigned, being duly sworn on oath state as follows:
1.
I was duly elected a (director/officer) of _______________________________________, at a
(members/directors) meeting held on _____________________________.
2.
I have not declared bankruptcy or been convicted of a criminal offense involving dishonesty or a
breach of trust or convicted for a violation of any laws of the United States or of any foreign state
relating to savings and loan associations.
3.
I am not an officer or director of another state or federal mutual savings and loan association to which
the Illinois Savings and Loan Act of 1985 applies.
4.
I have attached hereto a true and correct statement setting forth details as to the present and for the past
five (5) years, my business and professional resume, my business affiliations and my dealings with
any financial institution. Business affiliations means any office held, does not include compilation of
loans, checking accounts or savings accounts in various financial institutions.
Under penalty of perjury, I have placed my hand and seal this ______day of _______________, 20_____, at
_____________________, Illinois.
____________________________________
director/officer
Signed and sworn to before me this _______
day of _______________________, 20____.
____________________________________
Notary Public
IL 581-0034 (04-06)

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