ࡱ> PRO bjbj44 :JVV :jj8$4.(&(((((($L@@@Larrr@p&r@&rrr &ߓ.rw0r < r rL76rm,LLX@@@@ j :  STATE OF NEW JERSEY DEPARTMENT OF BANKING AND INSURANCE DIRECTORS AND EXECUTIVE OFFICERS STATEMENT OF INTEREST This form is to be used for reporting a business enterprise[s] which HAS a Business relationship with the designed bank. Name of designated bank:Name of reporting person:Title or position with designated bank: BUSINESS ENTERPRISE Name and address of business enterprise:Position with the business enterprise:Interest in the business enterprise:Business relationship between designated bank and the business enterprise: I do hereby certify that the above information is true and correct to the best of my knowledge and belief. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to the provisions of N.J.S.A. 41:3-1. Date: Signature:  (If NONE, so state). Use additional forms if necessary, sign each form. Also complete and sign an SI-1 Form. NOTIFICATION OF MATERIAL CHANGE OR ANNUAL REVIEW I do hereby certify that I have reviewed the information contained on the front of this form and the information contained therein reflects, to the best of my knowledge and belief my current status, except for the following changes: I am aware that if any of the foregoing statements made by me are willfully false, I am subject to provisions of the N.J.S.A. 41:3-1. Date: Signature:  INSTRUCTIONS FOR DIRECTORS AND EXECUTIVE OFFICERS STATEMENT OF INTEREST Business Enterprise Name and address: Give the legal name and address of the business enterprise. Position:List all positions held in the business enterprise by reporting person, his/her spouse or his/her minor children, identifying who holds the position. Interest:Specify the type of business and the nature and approximate percentage of ownership held by the reporting person, his/her spouse or his/her minor children. State the nature of any other form of influence exercised by the reporting person over the management or policies of the business enterprise. Specify if there is an indebtedness owed to or from the business enterprise by the reporting person, his/her spouse or his/her minor children, if the aggregate equals or exceeds the amount prescribed by regulation. Examples:Proprietorship; Corporation Stock owned by me 25%, by my wife 15% by my children 12%. Partnership Myself 25%, Son 25%; I have a loan from the company in excess of $50,000.00. Business: The Designated Relationship:Give a synopsis of the business relationship of the business enterprise with the Bank (See N.J.A.C. 3:7-5.1 for definition of business relationship). Examples:Borrowing; Letters of credit. Notification of Material Change or Annual Review This section may be used to reflect material changes between annual reviews. It may also be used to reflect and acknowledge the reporting persons annual review. If there is no change at the time of the annual review, so state. A new form should be filed in the event insufficient space is available to reflect changes. The above instructions are merely guidelines for the preparation of the Statement of Interest form. See regulation for specific requirements.     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