"Application for a Letter of Authority to Relocate a Credit Union Branch" - Pennsylvania

This "Application for a Letter of Authority to Relocate a Credit Union Branch" is a document issued by the Pennsylvania Department of Banking and Securities specifically for Pennsylvania residents with its latest version released on February 9, 2016.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Pennsylvania Department of Banking and Securities.

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Download "Application for a Letter of Authority to Relocate a Credit Union Branch" - Pennsylvania

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MARKET SQUARE PLAZA | 17 N SECOND STREET, 13TH FL | HARRISBURG, PA 17101
717.787.2665
717.787.8773
www.dobs.pa.gov
Ph
Fx
W
APPLICATION FOR A LETTER OF AUTHORITY
TO RELOCATE A CREDIT UNION BRANCH
Pursuant to the provisions of Section 904(b) of the Pennsylvania Credit Union Code, and for the purpose
of relocating a branch, the undersigned credit union hereby submits this application for a Letter of
Authority:
Name of applicant credit union and address of principal place of business:
Present branch location (address and county):
Proposed branch location (address and county):
Anticipated opening date of relocated branch:
Representative to be contacted for questions related to this application:
Name:
Telephone:
Title:
Facsimile:
Address:
E-Mail:
Page 1
Revised 2/9/2016
MARKET SQUARE PLAZA | 17 N SECOND STREET, 13TH FL | HARRISBURG, PA 17101
717.787.2665
717.787.8773
www.dobs.pa.gov
Ph
Fx
W
APPLICATION FOR A LETTER OF AUTHORITY
TO RELOCATE A CREDIT UNION BRANCH
Pursuant to the provisions of Section 904(b) of the Pennsylvania Credit Union Code, and for the purpose
of relocating a branch, the undersigned credit union hereby submits this application for a Letter of
Authority:
Name of applicant credit union and address of principal place of business:
Present branch location (address and county):
Proposed branch location (address and county):
Anticipated opening date of relocated branch:
Representative to be contacted for questions related to this application:
Name:
Telephone:
Title:
Facsimile:
Address:
E-Mail:
Page 1
Revised 2/9/2016
APPLICATION FOR A LETTER OF AUTHORITY
TO RELOCATE A CREDIT UNION BRANCH
(continued)
Resolution of the Board of Directors of
,
At a meeting of the Board of Directors duly called and held
on the following Resolution was adopted:
WHEREAS, it is the sense of this meeting that application should be made to the Department of
Banking and Securities of the Commonwealth of Pennsylvania for a Letter of Authority to relocate a
branch presently located at
to
;
NOW, THEREFORE, BE IT RESOLVED, that
,
of this credit union be hereby authorized and directed to prepare and file with the Department of
Banking and Securities an application, on behalf of this credit union, for a Letter of Authority to
relocate the aforesaid branch.
I CERTIFY that the above Resolution was adopted at a meeting of the Board of Directors held
; that the same has not been rescinded; that the number of duly elected
on
; that the number of Directors attending said meeting was
; and that
and qualified Directors is
voted in favor of the Resolution,
voted against the Resolution, and
abstained from voting on
the Resolution.
__________________________________________
SEAL
Signature of Secretary
Unsworn Declaration: I understand by submitting this Application for a Letter of Authority to Relocate a
Credit Union Branch I am agreeing to be bound by the following declaration: "I declare that all of my answers
on this Application for a Letter of Authority to Relocate a Credit Union Branch are complete, true and
correct. I make this declaration subject to the penalties of 18 PA.C.S. section 4904 relating to unsworn
falsification to authorities."
Page 2
Revised 2/9/2016
APPLICATION FOR A LETTER OF AUTHORITY
TO RELOCATE A CREDIT UNION BRANCH
(continued)
1. What are the distance and direction of the proposed branch location from the present branch
location?
2. Will the branch be operated in temporary quarters during relocation? If so, designate the type
of facility to be used and detail all anticipated costs and the terms and duration of occupancy of the
temporary office.
Yes
No
3. Indicate costs incidental to relocation of the branch and whether amounts represent purchase
or lease/rental expenses.
Purchase
Lease/Rental
Land ................................................................. $
$
Building ........................................................... $
$
Leasehold Improvements................................. $
$
Furniture, Fixtures, and Equipment ................. $
$
Other Related Expenses ................................... $
$
Total Cost of Branch ..................................... $
$
4. From whom will the premises be purchased or leased?
5. If the premises will be leased, describe terms of payment. Briefly detail options.
6. Are the premises and/or equipment to be purchased or leased from a director, officer, or
employee of the applicant credit union or an affiliated Credit Union Service Organization, or a
related interest of such individual as designated above (“Insiders”), or does any Insider have
any other financial, business, contractor, or any other interest in the proposed transaction? If
so, indicate names of any such Insiders, relationship of such to the applicant credit union, and cost of
recent comparable purchases or leases by the credit union. Attach a certified copy of the Resolution
of the Board of Directors approving the specific details of any such transaction.
Yes
No
Page 3
Revised 2/9/2016
APPLICATION FOR A LETTER OF AUTHORITY
TO RELOCATE A CREDIT UNION BRANCH
(continued)
7. Will any portion of the proposed branch location be leased or sub-leased to others? If so, list
name(s) of lessee(s), expected monthly rental income, and anticipated monthly expenses.
Yes
No
8. How many present members will be affected by the proposed branch relocation?
9. How many present and potential members will be served at the proposed branch location?
10. List the services to be provided to members at the proposed branch location.
11. List the services provided to members at the present branch location that will not be provided
at the proposed branch location.
12. State below reasons for filing this application and factors that support the need for the
proposed branch relocation. Any further information that would be helpful to the Department
of Banking and Securities should be supplied in this space or additional pages attached hereto.
Page 4
Revised 2/9/2016
APPLICATION FOR A LETTER OF AUTHORITY
TO RELOCATE A CREDIT UNION BRANCH
(continued)
Certificate of Official of Applicant Credit Union
I,
,
of this credit union, do hereby
certify that the information contained herein and contained in the attachments hereto is true and correct to
the best of my knowledge and belief and is submitted to the Department of Banking and Securities for the
purpose of requesting a Letter of Authority to relocate a branch.
__________________________________________
Signature of Officer
__________________________________________
Date of Application
Unsworn Declaration: I understand by submitting this Application for a Letter of Authority to Relocate a
Credit Union Branch I am agreeing to be bound by the following declaration: "I declare that all of my answers
on this Application for a Letter of Authority to Relocate a Credit Union Branch are complete, true and
correct. I make this declaration subject to the penalties of 18 PA.C.S. section 4904 relating to unsworn
falsification to authorities."
Page 5
Revised 2/9/2016
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