Information Technology Examination

of MDPS (Multi-regional Data Processing Servicer)
or TSP (Technology Service Provider)
or Financial Institution

THIS REPORT OF EXAMINATION IS STRICTLY CONFIDENTIAL

This copy of the examination report is the joint property of the FFIEC Member Agencies, and it is furnished for the confidential use of the examined entity. The information contained in this document is based upon the records and books of the entity, upon statements made by directors, officers, and employees, and upon information obtained from other sources believed to be reliable and correct.

This examination is not an audit and should not be construed as such. It is emphasized that this examination does not replace, nor relieve the management of its responsibility for making or providing for adequate audits of the examined entity.

Under no circumstances shall any recipient of this report, or any of its directors, officers, employees, outside auditor or legal counsel disclose or make public this report or any portion thereof. Unauthorized disclosure of any of the contents of this report is subject to the penalties in 18 U.S.C. 641. The agency that transmitted this report must be notified immediately if the examined entity receives a subpoena or other legal process calling for the production of this report.

FFIEC
Information Technology
Report of Examination

Data Center:

_______________________________________________________________________________________

City:

________________________

County:

____________________________

State:

____________

Zip:

____________

Date of examination:

Participating Agencies

Agency

Region/District

Number

EIC:

__________________________________

Examiner:

__________________________________

Examiner:

__________________________________

Examiner:

____________________________________

Examiner’s Conclusions………………………………………………………………………………C-1

Violations of Law and Regulations…….………………………………………..……………………C-1

Supporting Comments………………………………………………………………………………...C-1

Directors’ Signature Page…………………………………………………………………………….C-1

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We, the undersigned directors of the [Name of MDPS/TSP/Financial Institution], [City], [State and ZIP], have personally reviewed the contents of the report of examination dated [Date of Exam].

NAMES

SIGNATURES

DATES

Type first name here

_____________________________________________________

_______________________

Second name here

_____________________________________________________

_______________________

Third name here

_____________________________________________________

_______________________

_____________________________________________________

_______________________

_____________________________________________________

_______________________

_____________________________________________________

_______________________

_____________________________________________________

_______________________

NOTE: This form should remain attached to the report of examination and be retained in the institution’s file for review during subsequent examinations. The signature of committee members will suffice only if the committee includes outside directors and a resolution has been passed by the full board delegating the review to such committee.

RECAP:

Totals for all Institution Types:

Total National Banks:
Total State Member Banks:
Total State Non-Member Banks:
Total Thrifts:
Total Credit Unions:
____
Total All Institutions:
====

OTHER SERVICING:

# of Customers:

Applications Processed:

Part 5 - Condensed Balance Sheet and Income Statement for Nonfinancial Institution Servicer

                                                                                CONDENSED BALANCE SHEET As of December 31

                                                                                          200X             200X              19XX                19XX

CONDENSED INCOME STATEMENT As of December 31