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INTERNAL FR

UNIFORM DISCLOSURE FORM FOR SUPERVISION AND REGULATION PERSONNEL

Page 2

Employee Name (Last, First, Middle Initial)

Part II. ASSETS: List for you, your spouse and dependent children any direct or indirect equity or debt interest (including as a trustee or beneficiary of a trust), regardless of amount, in a domestic or foreign depository

institution, its holding company (bank or thrift) or a nonbank affiliate, a company that owns a bank, or any entity or person with whom you conduct business on behalf of the Bank. Also list any interest that arises from

participation by you or your spouse in a pension, retirement fund, or similar retirement plan with a current or former employer, and any shares of a mutual or closed-end fund that has a stated policy of concentration in the

financial services industry. [Exclude Federal Reserve retirement or thrift plan investments.] If none, write NONE or N/A.

The following table has 8 columns and 4 rows. The 3 data rows are left blank.

Header Row: Column 1 - Name of Organization and Location (City, State)

Header Row: Column 2 - Ownership

Header Row: Column 3 - Nature of Financial Interest (e.g.

Header Row: Column 4 - Date of

Header Row: Column 5 - Manner of Acquisition (e.g.,

Header Row: Column 6 - Administrative Use:

Header Row: Column 7 - Administra

Header Row: Column 8

Codes [See Footnote 5]

common stock, debentures, note

Acquisition

gift, inheritance, purchase)

receivable)

ID-RSSD

Permitted to

Required

Hold (Y/N)

Divestiture

Date

Next 3 data rows are left blank.

[End of the table]

Part III. OUTSIDE AND PRIOR EMPLOYMENT: List any position held, whether compensated or not, with an organization (corporation, company, firm, business enterprise, partnership, non-profit organization educational

institution or other organization) in which you serve as an employee, officer, owner, director, member, trustee, partner, adviser or consultant. Describe your position in each such organization, including current positions and

any held during the last 12 months. List any such position held by your spouse, child, parent or sibling with any entity with which you conduct business on behalf of the Bank (Exclude positions with religious, social, fraternal

or political entities, and those solely of an honorary nature.) If none, write NONE or N/A.

The following table has 7 columns and 4 rows. The 3 data rows are left blank.

Header Row: Column 1 - Name of Organization and Location (City, State) Header Row: Column 2 - Nature or Purpose of Organization Header Row: Column 3 - Position Held

Header Row: Column 4 - Dates Held, if known

Header Row: Column 5 - Administrative Use:

ID-RSSD

Header Row: Column 6 - Administrati

Header Row: Column 7

(Y/N)

Next 3 data rows are left blank.

[End of the table]

Part IV. RELATIVES IN BANKING: List any immediate family member (spouse, child, parent or sibling) who is an officer, director or employee of a depository institution or affiliate thereof, or a depository institution holding

company. If none, write NONE or N/A.

The following table has 6 columns and 4 rows. The 3 data rows are left blank.

Header Row: Column 1 - Name of Individual

Header Row: Column 2 - Relationship to Employee

Header Row: Column 3 - Name of Organization and Location (City, State)

Header Row: Column 4 - Position Held

Header Row: Column 5 - Administrative Use:

ID-RSSD

Header Row: Column 6 - Administ

Required (Y/N)

Next 3 data rows are left blank.

[End of the table]