Form FR T-4 FR T-4 Statement of Purpose for an Extension of Credit by a Cre

FR T-4
OMB No. 7100–0019
Approval expires March 31, 2008

BOARD OF GOVERNORS OF THE FEDERAL RESERVE SYSTEM

Statement of Purpose for an Extension of Credit by a Creditor
(Federal Reserve Form T-4)
Name of Creditor

This report is required by law (15 U.S.C. 78g and 78w; 12 CFR 220).
The Federal Reserve may not conduct or sponsor, and an organization (or a
person) is not required to respond to, a collection of information unless it
displays a currently valid OMB control number.

Public reporting burden for this collection of information is estimated to average
10 minutes per response, including the time to gather and maintain data in the
required form and to review instructions and complete the information
collection. Send comments regarding this burden estimate or any other aspect
of this collection of information, including suggestions for reducing this burden,
to Secretary, Board of Governors of the Federal Reserve System, 20th and C
Streets, N.W., Washington, DC 20551; and to the Office of Management and
Budget, Paperwork Reduction Project (7100-0019), Washington, DC 20503.

Instructions
1. This form must be completed only if the purpose of the credit being extended is not to purchase, carry, or trade in securities
and the credit is in excess of that otherwise permitted under Regulation T. (See § 220.6(e)(2)).
2. Please print or type (if space is inadequate, attach separate sheet).

Part I To be completed by customer(s)
1. What is the amount of the credit being extended?
2. The borrower acknowledges that no part of this credit will be used to purchase, carry, or trade in securities. The purpose
of the credit is described in detail as follows:

3. Are any of the securities listed in Part II to be delivered, or have any such securities been delivered from a bank, broker,
Yes
No
dealer, or other person on a “delivery against payment” basis?

I (We) have read this form and certify that to the best of my (our) knowledge and belief the information given is true, accurate,
and complete.
Signed:

Borrower’s signature

Print or type name

Signed:

Date

Borrower’s signature

Date

Print or type name

This form should not be signed if blank.

A borrower who falsely certifies the purpose of a credit on this form or otherwise willfully or intentionally evades
the provisions of Regulation T will also violate Federal Reserve Regulation X, “Borrowers of Securities Credit.”

FR T-4
Page 2 of 2

Part II

To be completed by creditor

The following is a listing of collateral, if any, securing this credit.
1. Collateral consisting of securities with loan value under Regulation T (refer to the Supplement to Regulation T).
No. of shares
or other unit

Market price

Date and source
of valuation
(See note below)

Total market
value per issue

Itemize separately by issue

Market price

Date and source
of valuation
(See note below)

Total market
value per issue

Itemize

Current
market value

Date and source
of valuation
(See note below)

Good faith
loan value

Itemize separately by issue

2. Collateral consisting of securities having no loan value under Regulation T.
No. of shares
or other unit

3. Other collateral.

Note: Creditor need not complete “Date and source of valuation” if the market value was obtained from regularly published or disseminated information in either a
journal of general circulation or an automated quotation system.

I am a duly authorized representative of the creditor. I have read this form and any attachments, and have accepted the
customer’s statement in Part I in good faith as defined below,* and I certify that to the best of my knowledge and belief, all the
information given is true, accurate, and complete.
Signed:

Date

Authorized representative’s signature

Title

Print or type name

* To accept the customer’s statement in good faith, the duly authorized representative of the creditor must be alert to the circumstances surrounding the credit and,
if in possession of any information that would cause a prudent person not to accept the statement without inquiry, must have investigated and be satisfied that the
statement is truthful. Among the facts which would require such investigation are receipt of the statement through the mail or from a third party.

This form must be retained by the lender for three years after the credit is extinguished.