Free 17720.pdf - Indiana

State Form 17720 (R/7-01)

DFI USE ONLY DATE RECEIVED ______________ INVOICE # ______CHECK#______ AMT. PD________BAL.DUE______ REFUND________WAR#________

APPLICATION FOR THE PROPOSED
_________________________________________ (Proposed Name of Credit Union) ____________________ ____________________ ________________ (City) (County) (State) This application is submitted to organize a State credit union pursuant to the Indiana code of 1971 28-7-1 and all acts amendatory thereof and supplemental thereto, TO THE DEPARTMENT OF FINANCIAL INSTITUTIONS 402 WEST WASHINGTON ST, ROOM W066 INDIANAPOLIS IN 46204-2759 GENERAL INSTRUCTIONS Please print or type this application. This application must be completed in triplicate and each copy signed by all incorporators. Signatures of incorporators must be original on all three copies. All questions must be answered in full. If the answer to a question is "no", "none", or "not applicable (N/A)", so state. Triplicate sets of Articles of Incorporation together with a set of by-laws, signed by all incorporators, must accompany this application at the time it is submitted to the Department. A check in the amount of $30.00 made payable to the Secretary of State of Indiana must accompany this application at the time it is submitted to the Department. If the space on this form is inadequate, use separate sheets of paper and attach same to this form ­ marking them Schedule 1, Schedule 2, etc. A defective or incomplete application may be rejected.

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Section 1 General Information 1. The proposed name of the credit union is: ________________________________________________________ 2. The mailing address of the credit union shall be: Street & Post Office Address City, State, Zip County 3. _____________________________ _____________________________ _____________________________

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The name, address, and telephone number of the key person is: _____________________ ___________________________ Name Telephone number _____________________ _________________ _______ ______ Address City State Zip This credit union shall have the following type of common bond: (a) (Please check one) Occupation ________ Trade ________ Professional Association ________ Labor Organization ________ Local Church ________ Farm Bureau Organization ________ Other (describe) __________________________________ (b) This common bond shall also include (please check one or more) Members of the immediate family ________ Organizations of such persons ________ Employees of the credit union ________ Once a member, always a member ________

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Define clearly the exact field of membership of this common bond to be served: _________________________________________________

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Is the common bond of a permanent nature? ____________________ Describe the territory or locations to be served: __________________ Do you plan to establish any service offices or branches in the near future? _____ If yes, give the locations. ________________________

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Are persons at these locations within the common bond? ___________ Are persons at these locations to be included in the field of membership?

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SECTION II Stability of the Associated Entity 1. The name and address of the entity comprising the common bond is: (If more than one, use attachment) Name of company or organization ________________________________________ Address City,State,Zip 2. ________________________________________ ________________________________________

What is the number of members or full-time employees of the entity comprising the common bond? ___________ What is the approximate number of family members of the group that is within the common bond, if applicable? __________ Describe the exact nature of business, or type of organization, of the entity ________________________________________________________ ________________________________________________________

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How many years has the entity been organized? _____________ Is the entity incorporated? _____________ What is the exact date of organization or incorporation of the entity? ____ Is this entity a subsidiary, affiliate, or division of a parent entity? ________ If yes, give the name and address of the parent entity. ____________________________________
____________________________________________ ____________________________________________

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Will any members or employees of the parent entity be eligible for membership? __________ Are the executives or officers of the entity favorable toward the organization of the credit union? ___________

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Give the name, title, and address of three who may be contacted. ____________________________________________________ ____________________________________________________ ____________________________________________________

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Is the entity willing to assist the credit union in communicating with the members? _________ Will the credit union be allowed to operate on the property of the entity? ______ If yes, what will be the cost to the credit union for this facility? ______ What type of security, if any, is available? ____________________ Is a system of payroll deduction available from the entity? ________ In your opinion, is the entity well established and will it continue indefinitely? _____ If no, explain _________________________________ Do you presently know of any plans the entity has of expanding, discontinuing, relocating, or moving out of state? ____________________ If yes, explain _______________________________________________ For the purpose of examining the stability of the entity, it would be most helpful if the incorporators would request information the entity may be willing to provide to assist in this determination of stability, which is prescribed by law. This information could include a financial statement if agreeable to the entity, however, failure to obtain such will not necessarily have an adverse effect on the determination of its stability. Any printed or published financial statement may be submitted. However, any such printed or published statement must be on the same size paper as the application itself (8.5"X 11"paper). Since the information on this financial statement may have a material effect in the decision of the Department, it shall be considered a part of the public record of this application.

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Section III Character and Management Qualification of Proposed Directors and Officers

Part A-General Information 1. Do the proposed directors and officers have a thorough knowledge of the Indiana Code as it affects the operation of credit unions? ______ If no, are they willing to obtain this knowledge on their own? _____ Are all proposed directors and officers familiar with the powers and duties delegated to them for the faithful performance of which the Department of Financial Institutions shall hold each responsible? _____ Are the proposed active officers experienced in keeping adequate records and books? _____ What will be the titles of the active chief executive officers? (Please check one or more) President Vice President Asst. Vice President 5. _____ _____ _____ Treasurer Asst. Treasurer Other (explain) _____ _____ _____

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Such active chief executive officers shall be? (Please check one) Volunteers, without pay, from among the group _____ Personnel, with pay, from among the group _____ Experienced personnel, without pay, from outside _____ Experienced personnel, with pay, from outside _____ Others (explain) __________________________________________

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What is the projected salary schedule, if any, of proposed officers and employees for the next three years? (This question shall be considered also in examining the economic feasibility of the credit union.) 20___ 20___ 20___ President or Treasurer _______ _______ _______ Vice President/Asst. Treasurer _______ _______ _______ Employees _______ _______ _______ Number of employees _______ _______ _______

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Part B-Detailed Information This part of the application should be completed by each director and each officer. This is a request for voluntary disclosure of personal information, but is deemed necessary by this Department in order to determine the general character and management qualification of proposed directors and officers as required by Section 1 of the Indiana credit Union Act (IC 28-7-1-1). Failure to disclose this information could result in denial of the application due to inadequate data. Since the information could have a material effect in the decision of the Department, it shall be considered a part of the public record of this application. 1. 2. 3. 4. 5. Name __________________________ Date of Birth _______________ Address ________________________ Place of Birth ______________ City, State, Zip ___________________ Length of residence _________ Marital Status ___________ Wife/Husband's name _________________ Trade names and/or other names used in place of given name ____________________________________ List civic, professional, social, or other organizations in which you have membership. _______________________________________________ __________________________________________________________ Resume of Education ________________________________________ __________________________________________________________ Employment record: (begin with present employment on first line and past employment on subsequent lines) From To Name, Location, and Type of Business Position & Duties _____ _____ ________________________________ ______________ _____ _____ ________________________________ ______________ _____ _____ ________________________________ ______________ Give details of all pending civil litigation of any nature in which you were involved either as plaintiff or defendant. Title and Nature of Proceeding __________________________________________ __________________________________________ Name & Address of Court __________________________________________ __________________________________________ Date ______________ ______________ Amount ______________ _______________

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Business Affiliations ­ List all firms, companies, corporations, or other business organizations of which you are at present a director, officer, employee, partner, or owner: Name, Location & Type of Business _______________________________ _______________________________ _______________________________ Position & Nature of Duties ______________________ ______________________ ______________________

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List below at least three references. (This could include any banks, finance companies, credit unions, business associates, or anyone else with whom you have been associated.) Address City, State, Zip Name ________________________________________________________ ________________________________________________________ ________________________________________________________

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Have you ever been adjudged a bankrupt or been involved with a receivorship or assignment for the benefit of creditors, or had to work out a compromise with your creditors? _____ If so, set forth the details below. Title & Nature of Proceeding Date __________________________________________ _____________ __________________________________________ _____________ Name & Address of Court Disposition __________________________________________ _____________ __________________________________________ _____________

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Have you ever been convicted of, or pleaded nolo contende to, any criminal offense involving dishonesty or breach of trust? ________________________________________________________

I hereby certify that the foregoing information is true and correct to the best of my knowledge and belief and that said information is submitted voluntarily by me to the Department of Financial Institutions. Date ______________ Signature _______________________

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Section IV Economic Feasibility 1. Does the group to compose the common bond presently have any form of savings plan available? _____ If yes, explain. __________________________________________________________ From which of the following does the group now have the availability of loan services? (Please check one or more.) Banks Credit Unions Savings & Loan Associations Finance Companies Other (explain) 3. ______ ______ ______ ______ ______________________________

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Do all or parts of the group presently have the availability of credit union membership or services? _____ If yes, give names and locations. _________________________________________________________ Describe any other financial services available within the general economic area to the group composing the common bond. _________________________________________________________ _________________________________________________________ _________________________________________________________

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Number of persons who attended the charter meeting. ____________ Does the group have leaders competent to operate a credit union and willing to sacrifice time and effort to this end? ____________________ Number of persons expressing a willingness to join the credit union. ___ On the following page is a list of signatures of at least one hundred persons who displayed interest in joining the credit union. (These signatures need not be obtained in triplicate, but may be reproduced when all are obtained. However, at least one set of original signatures must be submitted with the application.)

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Signatures of Persons Interested in Joining the Credit Union 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50

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Signatures of Persons Interested in Joining the Credit Union 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100

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We, the undersigned seven or more incorporators, all of whom are residents of the State of Indiana, of legal age, and representing a group of not less than five hundred persons having a common bond, as defined in the Articles of Incorporation, hereby make application to the State of Indiana Department of Financial Institutions to organize a State credit union and hereby bind ourselves to comply with all the laws, rules, and regulations of the State of Indiana applicable to credit unions and with the requirements of the Articles of Incorporation, in witness whereof, we have signed and acknowledged in triplicate and have annexed hereto. We hereby further certify, jointly and severally, that the statements contained herein are true to the best of our knowledge and belief. Respectfully Submitted, 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________

STATE OF INDIANA

)

County of ____________ )

The foregoing Application to organize a State credit union and the representations by the incorporators were subscribed and sworn to before me this _____ day of __________ , 20 ____ by the above named persons. Witness my hand and official seal. ________________________________ Notary Public My commission expires _____________

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CONFIDENTIAL BIOGRAPHICAL AND FINANCIAL REPORT
submitted by

_____________________________________________________________ of (Last Name) (First Name) (Middle Name)

________________________________________________________________ (Address) (City) (State) (Zip)

to THE DEPARTMENT OF FINANCIAL INSTITUTIONS, STATE OF INDIANA, in connection with an application for the organization of:

Please type or print this report which is to be completed by each applicant, director, and managing officer ­ existing or proposed ­ and submit twelve copies for the Members confidential use in evaluating an application in which the submitter is a party. Each item of the report should be completed by entry of the data or insertion of the words "none" or "N/A". If any space provided is insufficient, a signed supporting statement should be attached.

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PART 1

Social Security Number Date of Birth Place of Birth Citizenship Marital Status Husband's full name Wife's full maiden name Children ­ Names and ages

________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________

________________________________________________________________

If divorced, give name(s) of previous spouse(s) and any current alimony arrangements. ________________________________________________

________________________________________________________________

Educational background ____________________________________________ ________________________________________________________________

Residences within past 15 years ­ list cities and, if readily available, all street addresses, with period covered by each. _______________________________ ________________________________________________________________

Occupation ______________________________________________________

Employers ­ list all within past 15 years and period covered by each, including any period(s) of self-employment _____________________________________ ________________________________________________________________ ________________________________________________________________

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Have you ever been adjudged a bankrupt or compromised with creditors? If so, give details including court(s) in which proceedings were conducted, indicating ultimate disposition of the claims of creditors.

Have you ever been affiliated with a business that has been adjudged bankrupt or compromised with creditors? If so, give details including court(s) in which proceedings were conducted, indicating ultimate disposition of the claims of creditors.

Have you ever been charged (Include charges even if they were dismissed and include court martials while in military service and include actions involving breach of trust) or convicted in a legal proceeding with the commission of a criminal offense other than a traffic violation for which you paid a fine of $30.00 or less and an offense committed prior to your sixteenth birthday (if the answer is in the affirmative, the circumstances, including the nature of each offense referred to and the date and place of charge or conviction, must be explained in detail).

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PART II

FINANCIAL STATEMENT AS OF ___________, 20 ___

ASSETS** Cash on hand and in banks U.S. Government bonds Other creditor securities Stocks (a) Other proprietary interests (including closely held corporations) (a) Cash surrender value of life insurance Notes and other debts receivable Real estate owned (b) Other assets Total Assets LIABILITIES Notes and accounts payable Real estate mortgages payable Other debts secured by assets owned Judgments outstanding (c) Other liabilities TOTAL LIABILITIES Net worth Total liabilities and Net Worth Contingent liabilities (d) Indirect liabilities (e) Lawsuits pending (f) _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________

List and describe any substantial changes in the above anticipated within the next year

*Subsidiary schedules to the Financial Statement are keyed to certain items. **If any asset is not owned outright or is recorded as owned in other than your own name solely, please attach a signed explanatory schedule.

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(a) List as to stock and proprietary interests in financial institutions and businesses handling real estate, hazard insurance, home construction, land development, building supplies, or mortgage brokerage ­ attaching separate sheets (signed) if needed. Name of Institution Incorporated or unincorporated? Nature of activity

Value of your interest Latest annual return or loss on your interest

(b)

Real estate owned (For each parcel included give the following

information ­ attaching separate sheets (signed if needed)

Location and brief description of property

Fair market value

Liens outstanding ­ amounts and holders

Equity

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(c)

Judgments outstanding (Please give all pertinent details)

(d)

Contingent Liabilities (Please give all pertinent details)

(e)

Indirect Liabilities (Please give all pertinent details)

(f)

Lawsuits pending (Please give all pertinent details; in addition to personal lawsuits in which you are a defendant, include any case involving a corporation in which you are an officer or substantial stockholder.)

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STATEMENT OF INCOME

Latest annual salary and net income from other sources ­ itemize.

I CERTIFY that the information contained in this questionnaire has been carefully examined by me and is true, correct and complete, and that said information and statement of financial condition are submitted voluntarily by me to the Department of Financial Institutions for its confidential use subject to I.C. 1971 28-1-2-30 (Burns 18-229)

_______________________________ (Signature in Full) _______________________________ (Typed or Printed Name) _______________________________ (Date of Signature)

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Articles of Incorporation ARTICLE I
The name of this corporation is _______________________________________________ Credit Union, of ____________________________________________________, Indiana.

ARTICLE II
The post office address of the principal office of this corporation is: _________________________________ Street Number _________________________________ City, State, Zip _________________________________ (County)

ARTICLE III
The purposes for which this corporation is formed are _____________________ ________________________________________________________________ ________________________________________________________________

ARTICLE IV
The period during which this corporation shall continue as a corporation is unlimited.

ARTICLE V
The qualification for membership in this credit union shall be: ________________________________________________________________ ________________________________________________________________

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ARTICLE VI
The capital stock of this corporation is member-shares. The credit union may issue shares of stock, the par value shall be _________________.

ARTICLE VII
The maximum number of Directors of this corporation shall be ____________.

ARTICLE VIII
The name, post office address and term of office of each member of the First Board of Directors are as follows: Name 1. 2. 3. 4. 5. 6. 7. Post Office Address Term of Office

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ARTICLE IX
The name and post office address of each of the incorporators and the number of shares subscribed by each of them are as follows: Name 1. 2. 3. 4. 5. 6. 7. Post Office Address Term of Office

(Note: Additional articles may be included to state any other provisions, consistent with the laws of this state relative to Credit Unions, for the regulation, operation, or limitation of the business or powers of the union, its directors and shareholders.)

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IN WITNESS WHEREOF, we have hereunto signed our names in triplicate this ________ day of ________________, 20_________

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__________________________________________

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__________________________________________ STATE OF INDIANA )

COUNTY OF _______________ ) Personally appeared before me the undersigned, a Notary Public within and for the aforesaid County and State, the within named __________________ ________________________________________________________________ who acknowledged the execution of the foregoing Articles of Incorporation. WITNESS my hand and Notarial seal this ____ day of ______________, 20____

____________________________________ (Notary Public) My Commission Expires ____________ (Note: At the time of filing of the above application, the incorporators are required to submit a set of By-laws with the acknowledgment of their adoption by the incorporators as provided by the Act.)

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