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APPLICATION TO ORGANIZE A STATE CHARTERED FINANCIAL INSTITUTION
State Form 50943 (R / 1-08)

DEPARTMENT OF FINANCIAL INSTITUTIONS

Date of Application

Projected Opening Date

The incorporators make application to The Department of Financial Institutions of the State of Indiana for the establishment of a financial institution to be organized as a:

COMMERCIAL BANK

SAVINGS BANK

INDUSTRIAL LOAN AND INVESTMENT COMPANY PROPOSED FINANCIAL INSTITUTION
Name Address of main office City County State ZIP Code

The executed applications, including all supporting documents for this portion of the application, are to be submitted to:

THE DEPARTMENT OF FINANCIAL INSTITUTIONS 30 SOUTH MERIDIAN STREET, SUITE 300 INDIANAPOLIS, INDIANA 46204
The Department should contact the following individual for additional information:

Name of Contact Person

Telephone Number

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GENERAL INSTRUCTIONS To promote consistency and reduce regulatory burden, the Department of Financial Institutions has adopted the Interagency Charter and Federal Deposit Insurance Application ("Interagency Application") used by the Office of the Comptroller of the Currency, the Office of Thrift Supervision, and the Federal Deposit Insurance Corporation. 1. A majority of the Incorporators or Organizers, Directors and Executive Officers of the proposed financial institution must participate in a meeting in the office of the Department of Financial Institutions prior to filing the application to discuss the proposed financial institution. Seven (7) copies of the Interagency Application, supporting documents, and additional information requested in these general instructions should be filed. The fees and related expenses may be obtained by calling the Department of Financial Institutions at (317) 232-3955. Provide four (4) copies of the proposed Articles of Incorporation. The Articles of Incorporation should be completed in accordance with I.C. 28-12-2. The Department will provide a draft copy of Articles of Incorporation containing the minimum requirements. Each incorporator, director, and officer of the proposed financial institution must The financial and file confidential financial and biographical reports. biographical reports must be filed on either the Interagency Biographical and Financial Report filed in conjunction with the application submitted to the Federal Regulatory Agency or the Department's Confidential Financial and Biographical Report. Fingerprint cards need not be submitted to the Department of Financial Institutions. If the proposed financial institution will be controlled by an existing bank holding company (as control is defined in I.C. 28-2-14 or I.C. 28-2-16), provide an organizational chart of the bank holding company, detailing parent company, and all subsidiaries and affiliates. Provide a copy of the prospectus or offering circular. Although the Department has not promulgated specific rules concerning the contents of a prospectus or offering circular, it must include a statement to the effect that the Department of Financial Institutions has not approved or disapproved the securities being offered or passed upon the accuracy or adequacy of the offering circular or prospectus. Any offering of securities is subject to the general anti-fraud provisions of the state and federal securities laws. Under the anti-fraud provisions, a particular fact is generally considered material if there is a substantial likelihood that a reasonable person would consider the fact of significance in making an investment decision relating to the securities offered.

2.

3.

4.

5.

6.

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Therefore, in preparing that document, the Applicant should be guided by the principles and standards that have been developed under relevant federal and state securities laws and the Federal Deposit Insurance Corporation's Policy Statement on the Use of Offering Circulars in Connection With the Public Distribution of Bank Securities. 7. The Department requires annual external audits pursuant to IC 28-13-10-8. Provide the name of the CPA firm the applicant has chosen to perform the external audit. Also, describe any other services, i.e. tax preparation or internal audit, which the CPA firm will perform. If the applicant intends on using a Mobile Unit or Messenger Service to provide services, provide a copy of the agreement, and if applicable, a description of the services to be provided and the geographic area which will be served. The Department of Financial Institutions expects the applicant to comply with all statements and commitments made in the application. If there is any change in the proposal or amendments are made to the Interagency Application, the applicant should immediately notify the Department.

8.

9.

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I.

ORGANIZATION EXPENSES

INSTRUCTIONS: List all expenses related to the organization of the financial institution. Include all expenses paid, additional costs anticipated prior to the opening date, and any expenses for work performed during the organization phase for which disbursement may be deferred beyond the opening date. Type of Relationship (Specify) Director, Officer, 5% Stock Holder, or their Relative or Business Interest

Name of Recipient

Association with Financial Institution

Amount

Attorney Fees: a) TOTAL ATTORNEY FEES Consultant Fees: b) TOTAL CONSULTANT FEES Pre-opening salaries: c) TOTAL PRE-OPENING SALARIES d) TOTAL PRE-OPENING TRAVEL & ENTERTAINMENT e) TOTAL APPLICATION & INVESTIGATION FEES OTHER EXPENSES:
(Describe in detail any item in excess of ($10,000)

f) TOTAL OTHER EXPENSES TOTAL ORGANIZATION EXPENSES
(Sum of lines 1 thru 6 above)

PRE-OPENING INCOME TOTAL
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1.

Describe the Source of all Pre-opening income.

2.

Describe How Organizational Expenses will be paid.

II.

GENERAL INFORMATION 1) Has any proposed director, officer, or employee been convicted of a felony or any criminal offense involving dishonesty or a breach of trust? (If "Yes" explain below). Yes No

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III.

APPOINTMENT OF AGENT (Please type)

The incorporators of the proposed
TYPE OF INSTITUTION TO BE FORMED

appoint and designate
FIRST NAME MIDDLE NAME LAST NAME

NUMBER AND STREET

CITY AND STATE

ZIP CODE

TELEPHONE NUMBER

as our sole and exclusive agent revoking all previous appointments of agency to organize this state on . The AGENT is authorized to represent and appear on behalf of the undersigned before the DEPARTMENT OF FINANCIAL INSTITUTIONS (DEPARTMENT) and, except where the DEPARTMENT shall require personal actions by the incorporators, the agent is empowered and authorized to do and perform all things necessary in connection with the application as the incorporators could do if personally present. The AGENCY RELATIONSHIP shall terminate when the Articles of Incorporation of the proposed financial institution are filed with the Secretary of State. The AGENCY RELATIONSHIP may only be revoked by a certified resolution of the incorporators to the DEPARTMENT. I certify, as agent, that I am not a party to any agreement other than with the signers of the APPOINTMENT OF AGENT concerning this application, dated .
SIGNATURE OF AGENT DATE

The undersigned further authorize the DEPARTMENT to investigate the character, financial responsibility, and criminal background of the undersigned. The undersigned shall reimburse the DEPARTMENT for expenses incurred in the investigation.

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These statements are true to the best of our knowledge and belief. The DEPARTMENT is requested to make thorough investigation of this application to determine approval or disapproval. (To be signed by all incorporators.) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

STATE OF INDIANA COUNTY OF

) ) SS: )

The Application to establish a state , Appointment of an Agent, and Representations by the Incorporators were subscribed and sworn to before me this day of ,by the above persons. Witness my hand and official seal. My commission expires:
DATE

NOTARY PUBLIC

(SEAL)

PRINTED NAME

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