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CCB-1123 (Rev. 09/12)
PERSONAL FINANCIAL REPORT AND DISCLOSURE STATEMENT
INSTRUCTIONS
This form is generally filed by directors or officers of existing financial institutions and
in conjunction with applications for various certificates of authority and licenses pursuant to
Title 6.2 of the Code of Virginia. The information provided on this form must be current (less
than 90 days old at the time of filing with the Bureau) and accurate. The form and its contents
are confidential. The report must be executed with original signature(s). In completing the
form, please follow the instructions below:
1. An answer to each item is required. If your answer is "No", "None", "Not Applicable", or
"Unknown", please indicate that on the question or schedule.
2. File any additional attachments and/or schedules on 8 ½" x 11" paper if space provided on
the form is inadequate. Sign and date all such schedules.
3. Have your spouse co-sign this form if assets and liabilities are jointly held with him/her.
4. If you are a bank or savings institution director filing this form pursuant to §§ 6.2-864 or 6.2-
1121 of the Code of Virginia, have an officer of the bank or savings institution countersign
this form.
5. Attach a separate financial statement for any business in which you have an ownership
interest if a substantial portion (25 percent or more) of your net worth is tied to such a
business. Your interest in such business should also appear in Schedule C on page 4 of this
form, and the net annual income derived from such an interest should appear on the
Statement of Income (page 3).
A Personal Financial Report and Disclosure Statement form containing false or
misleading information raises questions about the character, integrity, and fitness of a director,
officer, or principal of a financial institution. Therefore, it is imperative that you provide true
and complete information as requested herein. Additionally, each filer must report promptly
any material change in his/her financial condition or personal information that occurs
during the review period of this filing.
Inquiries regarding the preparation and filing of this form should be directed to the
Bureau of Financial Institutions, 1300 East Main Street, Suite 800, Post Office Box 640,
Richmond, Virginia 23218-0640. Telephone: (804) 371-9690; FAX (804) 371-9416. This form
can be downloaded from the Bureau’s website at www.scc.virginia.gov/bfi.