8000 - Miscellaneous Statutes and Regulations
Appendix B to Part 103Certification for Purposes of
Section 314(b) of the
Certification for Purposes of Section 314(b) of the
I hereby certify, on behalf of (insert name, address, and federal employer identification number (EIN) of financial institution or association of financial institutions) _______ _______ _______ ____________________________________________ that:
(1)(i) The financial institution specified above is a "financial institution" as such term is defined in 31 CFR 103.110(a)(2), or (ii) The association specified above is an "association of financial institutions" as such term is defined in 31 CFR 103.110(a)(3).
(2) The financial institution or association specified above intends, for a period of one (1) year beginning on the date of this certification, to engage in the sharing of information with other financial institutions or associations of financial institutions regarding individuals, entities, organizations, and countries, as permitted by section 314(b) of the USA PATRIOT Act of 2001 (Public Law 107-56) and the implementing regulations of the Department of the Treasury, Financial Crimes Enforcement Network (31 CFR 103.110).
(3) The financial institution or association of financial institutions specified above has established and will maintain adequate procedures to safeguard the security and confidentiality of such information.
(4) Information received by the above named financial institution or association pursuant to section 314(b) and 31 CFR 103.110 will not be used for any purpose other than as permitted by 31 CFR 103.110(c)(2).
(5) In the case of a financial institution, the primary federal regulator, if applicable, of the above named financial institution is ____________________________________________ .
(6) The following person may be contacted in connection with inquiries related to the information sharing under section 314(b) of the USA PATRIOT Act and 31 CFR 103.110:
MAILING ADDRESS: _______ _______ _______
E-MAIL ADDRESS: _______
TELEPHONE NUMBER: _______
FACSIMILE NUMBER: _______
BY: ____________________________________________ Name ____________________________________________ Title Executed on this _______ day of _______ , 200 _______ .