Application for Consent to Increase Trust Powers

State of Louisiana
OFFICE OF FINANCIAL INSTITUTIONS
Post Office Box 94095
Baton Rouge, Louisiana 70804-9095

Application for Consent to INCREASE TRUST POWERS

Name of Financial Institution
Main Office Location
City	State
General InformationAn original and one copy of the completed Application are to be forwarded to the Commissioner of Financial Institutions, Office of Financial Institutions, Post Office Box 94095, Baton Rouge, Louisiana 70804-9095. A completed copy should be retained by the financial institution.Requests for clarification as to what information is necessary to complete this form should be directed to the Office of Financial Institutions.The financial institution may provide any information in addition to that requested by the Office of Financial Institutions which, in its opinion, might aid in the evaluation of the Application. However, any such information can be accepted for consideration only with the understanding that it may be made public.

OFFICE OF FINANCIAL INSTITUTIONS
Post Office Box 94095
Baton Rouge, Louisiana 70804-9095

The ____________________ , ______________________ , hereby makes application for
(Name of Institution) (City)

written consent of the Office of Financial Institutions to ________________________________________

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This application is made pursuant to authorization and direction of the Board of Directors of this financial institution, as evidenced by the following resolution adopted on the _____day of ____ , 19____ .

RESOLVED, that an application be made by this financial institution for the written consent of the Office of Financial Institutions to ______________________________________________________________

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FURTHER RESOLVED, that the President or Vice President, and the Cashier or Secretary of this financial institution are authorized and directed, on behalf of this financial institution, to execute and submit such application to the Office of Financial Institutions;

Additional evidence in support of this application is attached to and made a part thereof.

Name of Financial Institution ____________________________________________________

City/Parish/Louisiana __________________________________________________________

Date: __________________________

By: __________________________
(President or Vice President)

Attest: _________________________
(Cashier or Secretary)

Will the increase in trust powers result in a change in the trust department, management, trust committee, or legal counsel? Yes [ ] No [ ]

If No is checked, complete the resolution page and state the reasons why additional personnel will not be necessary to accommodate the increase in trust powers and submit the applicaiton to this Office. _________________________________________________________________________

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If Yes is checked, complete the resolution page, the following questions, and submit the application to this Office.

1. The trust powers referred to in this application are confined to those checked below:

Executor and administrator [ ]	Custodian [ ]
Trustee [ ]	Corporate Trustee [ ]
Guardian [ ]	Corporate Agent [ ]
Committee	Agent [ ]
Registrar of stocks and bonds [ ]	Transfer Agent [ ]
Other (specify) [ ]

2. Give name, age, title, salary, and elaborate fully on duties, experience, and qualifications of: (use additional pages, if necessary.)

(a) Trust Officer(s)

Name	Age	Title	Salary
Duties :
Experience :
Qualifications :

Name	Age	Title	Salary
Duties :
Experience :
Qualifications :

Name	Age	Title	Salary
Duties :
Experience :
Qualifications :

(b) Trust Committee

Name	Age	Title	Salary
Duties :
Experience :
Qualifications :

Name	Age	Title	Salary
Duties :
Experience :
Qualifications :

Name	Age	Title	Salary
Duties :
Experience :
Qualifications :

Name	Age	Title	Salary
Duties :
Experience :
Qualifications :

Name	Age	Title	Salary
Duties :
Experience :
Qualifications :

Name	Age	Title	Salary
Duties :
Experience :
Qualifications :

Name	Age	Title	Salary
Duties :
Experience :
Qualifications :

3. Information relating to operations:

(a) Indicate the reasons for and intent of offering trust services and summarize any associated marketing plans. Are trust services intended to become a material segment of the financial institution’s operations?

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(b) Please submit to this Office specific budget projections and pro forma financial statements for the first three years of operation. If profitability is not anticipated within the first three years, document the anticipated time frame for the Department to become profitable. (This information may be submitted in a separate attachment.)

(c) Provide details (name, address, qualifications, etc.) of any proposed investment advisors to be used and the method(s) of selection.

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(d) Provide details of proposed accounting/record keeping methods to be used in servicing fiduciary accounts.

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(e) Provide details of any anticipated investment that will be required to provide for formation and implementation of the Trust Department and its related activities.

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4. In support of this application, the following data is requested:

(a) Disclose all trust related contingent liabilities present at the date of this application, giving the nature and amount of the contingent liability, parties involved, anticipated settlement date, and probable outcome.

_______________________________________________________________

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(b) The following changes have been made in the directors and officers of the financial institution since it was last examined by the Office of Financial Institutions (if none, so state).

Name Address & Occupation	Age	Position	Title /Net Worth	Annual Salary	Par Value of Stock Owned Pref/Common

(c) Does the institution possess fidelity insurance covering active trust department offices and employees, as well as contemplated changes therein to accommodate the anticipated increase in trust activity?

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