Supplemental Report

U.S. Department of the Treasury

Initial Supplemental Report for Banks Participating in the Small Business Lending Fund
This Initial Supplemental Report supplements the Report of Condition and Income filed by a bank that will receive capital from the U.S. Department
of the Treasury (Treasury) through the Small Business Lending Fund. This Initial Supplemental Report must be filed within 5 business days prior to
the closing date, must be signed by the Chief Executive Officer (CEO) and the Chief Financial Officer (CFO) of the reporting bank (or by the
individuals performing equivalent functions), and must be attested to by no fewer than two directors (trustees) for State nonmember banks and
three directors for State member and National banks.
We, the undersigned CEO and CFO (or equivalents) of the named bank,
attest that the Initial Supplemental Report for this report date has been
prepared in conformance with the instructions issued by the Treasury
and is true and correct to the best of our knowledge and belief.
_______________________________________________
Signature of Chief Executive Officer (or Equivalent)
_______________________________________________
Date of Signature
_______________________________________________
Signature of Chief Financial Officer (or Equivalent)
_______________________________________________
Date of Signature
_______________________________________________
Legal Title of Bank
Select State
_______________________________________________
City
State
Zip

We, the undersigned directors (trustees), attest to the correctness of the
Initial Supplemental Report for this report date and declare that the Initial
Supplemental Report has been examined by us and to the best of our
knowledge and belief has been prepared in conformance with the
instructions issued by the Treasury and is true and correct.
________________________________________________
Director (Trustee)
________________________________________________
Director (Trustee)
________________________________________________
Director (Trustee)

SBLF #
FDIC Certificate #

Submission of Report: Please refer to Instructions for Initial Supplemental Report document for submission information.
Freedom of Information Act
Please note that any information submitted by applicants may become
subject to public disclosure pursuant to the terms of the Freedom of
Information Act, 5 U.S.C. 552 (FOIA) and its exemptions. Nevertheless,
Treasury’s FOIA regulation, 31 C.F.R. 1.1 et seq., provides that, in
certain cases, businesses that submit information to Treasury shall
receive notice of a pending FOIA request for that information as well as
an opportunity to object to the disclosure of any or all of that
information on the grounds that the information qualifies for
withholding under FOIA Exemption 4. See 31 C.F.R. 1.6.
To facilitate this business submitter notification process, Treasury
encourages applicants to designate any such information that they
believe, in good faith, is subject to FOIA Exemption 4. Such
designations will help Treasury to recognize instances in which
business submitter notification may be appropriate. Treasury reserves
sole discretion to determine whether such designated information
indeed qualifies for business submitter notification and ultimately,
whether it qualifies for withholding pursuant to FOIA Exemption 4.
If you wish to identify any information on this form that you believe is
subject to FOIA Exemption 4, please identify that information and the
reasons for your request on attached pages.

SBLF Institution Wire and Contact Information:
Please provide the following information to allow Treasury to wire
funds to your institution:
Bank Name: ______________________________________________
ABA (Routing) Number: ____________________________________
Account Number: _________________________________________
Account Name: ___________________________________________
Beneficiary: ______________________________________________
Primary Wire Contact Name: ________________________________
Primary Wire Contact Phone Number: ________________________
Primary Wire Contact Email Address:
________________________________________________________
Secondary Wire Contact Name: ______________________________
Secondary Wire Contact Phone Number: ______________________
Secondary Wire Contact Email Address:
________________________________________________________
Wire Information SBLF Institutions Should Use to Make Dividend or
Interest Payments to Treasury:
Bank Name:
The Bank of New York Mellon
ABA (Routing) Number: 021000018
BNF Acct Name:
Income Collection
BNF Acct Number:
111566
REF:
Private Placements – SBJA
Security Name & Cusip

Initial Supplemental Report for Banks
Treasury Department Form: TD F 102.3

1

OMB Number: 1505-0228

Initial Supplemental Report
for Banks Participating in the Small Business Lending Fund

Table of Contents
Initial Baseline Calculation
Initial Adjusted Baseline Calculation
Initial Quarter-End Qualified Small Business Lending
Dividend Rate Calculation
Every bank participating in the Small Business Lending Fund (SBLF) of the U.S. Department of the Treasury (Treasury) is required to
submit an Initial Supplemental Report within five business days prior to the closing date of the SBLF funding. Please refer to the
Instructions for the Initial Supplemental Report for Banks Participating in the Small Business Lending Fund for guidance.
The bank must also submit Quarterly Supplemental Reports, beginning in the quarter in which the funding occurs, as described in
the separate Instructions for the Quarterly Supplemental Report for Banks Participating in the Small Business Lending Fund.
If you have general questions regarding this form, please contact the information line for the Small Business Lending Fund
at 888-832-1147 (Monday-Friday, 9:00 AM-7:00 PM ET).

The Federal Government may not collect, and the public is not required to respond to, a collection of information that does not display a currently valid OMB Control Number. The control
number for this collection is 1505-0228.

Initial Supplemental Report for Banks
Treasury Department Form: TD F 102.3

2

OMB Number: 1505-0228

Initial Supplemental Report
for Banks Participating in the Small Business Lending Fund

Initial Baseline Calculation
All banks participating in the Small Business Lending Fund must complete this Initial Baseline Calculation. If the amount of Qualified
Small Business Lending increased as a result of mergers, acquisitions, or loan purchases from 10/1/09 through 6/30/10, use the
Worksheet A in the instructions for completing this form to determine amounts for lines 1-4. All figures are to be reported in
thousands of dollars. Report the amount outstanding as of the last day of the quarter being requested.
9/30/09
Dollar amounts in thousands
Bil
1. Balances of commercial
and industrial loans (as
reflected on Call Report
Schedule RC-C, Part1,
1a
Item 4)
2. Balances of loans secured
by owner-occupied
nonfarm nonresidential
properties (as reflected on
Call Report Schedule RC-C,
Part I, item 1.e.(1))
2a
3. Balances of loans to
finance agricultural
production and other
loans to farmers (as
reflected on Call Report
Schedule RC-C, Part I,
item 3)
3a
4. Balances of loans secured
by farmland (as reflected
on Call Report Schedule
4a
RC-C, Part I, item 1.b)
5. Subtotal (sum lines 1-4)
6. Dollar portion of any such
loans or group of such
loans to the same
borrower and its affiliates
with an original principal
or commitment amount
greater than $10 million
7. Dollar portion of such
loans to businesses with
more than $50 million in
revenues, unless included
in line 6
8. Dollar portion of line 5
guaranteed by the U.S.
government, unless
included in lines 6 or 7
9. Dollar portion of line 5
where a third party has
assumed an interest,
unless included in lines 6,
7, or 8
10. Total (line 5 minus lines 6,
7, 8, and 9)
11. Total of four quarters’
qualified loans (sum line
items 10a through 10d)

Mil

Thou

12/31/09
Bil

3/31/10
Mil

Thou

6/30/10
Bil

Mil

Thou

Bil

1b

1c

1d

2b

2c

2d

3b

3c

3d

4b

4c

4d

5a

5b

5c

5d

6a

6b

6c

6d

7a

7b

7c

7d

8a

8b

8c

8d

9a

9b

9c

9d

10a

10b

10c

10d

12. Initial Small Business Lending Baseline (line 12 equals line 11 divided by 4)

Mil

Thou

Total of Four Quarters
Bil
Mil

11
12

Initial Supplemental Report for Banks
Treasury Department Form: TD F 102.3

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OMB Number: 1505-0228

Initial Supplemental Report
for Banks Participating in the Small Business Lending Fund

Initial Adjusted Baseline Calculation
All banks participating in the Small Business Lending Fund must complete the Initial Adjusted Baseline Calculation. All figures are to
be reported in thousands of dollars. Amounts should reflect information published in the quarter prior to the quarter in which the
closing date occurs. Therefore, data shown should be as of two quarters prior to the quarter in which the closing date occurs.
Dollar amounts in thousands
13. Initial Small Business Lending Baseline (line 12)

Bil

Mil

Thou

13

14. Balance increases in commercial and industrial loans resulting from an acquisition of, or merger with, another institution, and purchases of such loans on or
after 7/1/2010
15. Balance increases in loans secured by owner-occupied nonfarm nonresidential properties resulting from an acquisition of, or merger with, another
institution, and purchases of such loans on or after 7/1/2010
16. Balance increases in loans to finance agricultural production and other loans to farmers resulting from an acquisition of, or merger with, another
institution, and purchases of such loans on or after 7/1/2010
17. Balance increases in loans secured by farmland resulting from an acquisition of, or merger with, another institution, and purchases of such loans on or after
7/1/2010
18. Subtotal (sum lines 14, 15, 16, and 17)

14
15
16
17
18

19. Dollar portion of any such loans or group of such loans to the same borrower and its affiliates with an original principal or commitment amount greater
than $10 million
20. Dollar portion of any such loans to businesses with more than $50 million in revenues, unless included in line 19

19
20

21. Dollar portion of line 18 guaranteed by the U.S. government, unless included in line 19 or 20

21

22. Dollar portion of line 18 where a third party has assumed an interest, unless included in line 19, 20, or 21

22

23. Qualified balance increases (line 23 equals line 18 minus lines 19, 20, 21, and 22)
24. Initial Adjusted Small Business Lending Baseline (line 24 equals line 13 plus line 23)

23
24

Initial Quarter-End Qualified Small Business Lending
All banks participating in the Small Business Lending Fund must complete this section. All figures are to be reported in thousands of
dollars. Amounts should reflect information published in the quarter prior to the quarter in which the closing date occurs.
Therefore, data shown should be as of two quarters prior to the quarter in which the closing date occurs.
Quarter End
Bil
Mil

Dollar amounts in thousands
25. Balances of commercial and industrial loans (as reflected on Call Report Schedule RC-C, Part I, item 4)

25

26. Balances of loans secured by owner-occupied nonfarm nonresidential properties (as reflected on Call Report Schedule RC-C, Part I, item 1.e.(1))
27. Balances of loans to finance agricultural production and other loans to farmers (as reflected on Call Report Schedule RC-C, Part I, item 3)

28

29. Subtotal (sum lines 25, 26, 27, and 28)

29

30. Dollar portion of any such loans or group of such loans to the same borrower and its affiliates with an original principal or commitment amount greater
than $10 million

32. Dollar portion of line 29 guaranteed by the U.S. government, unless included in line 30 or 31
33. Dollar portion of line 29 where a third party has assumed an interest, unless included in line 30, 31, or 32
34. Total qualified small business loans (line 34 equals line 29 minus lines 30, 31, 32, and 33)

26
27

28. Balances of loans secured by farmland (as reflected on Call Report Schedule RC-C, Part I, item 1.b)

31. Dollar portion of such loans to businesses with more than $50 million in revenues, unless included in line 30

30
31
32
33
34

Initial Supplemental Report for Banks
Treasury Department Form: TD F 102.3

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OMB Number: 1505-0228

Initial Supplemental Report
for Banks Participating in the Small Business Lending Fund
Net Charge-Off Adjustments
Net charge-offs on or after
7/1/2010
Bil
Mil
Thou

Dollar amounts in thousands
35. Net charge-offs on commercial and industrial loans on or after 7/1/2010

35

36. Net charge-offs on loans secured by owner-occupied nonfarm nonresidential properties on or after 7/1/2010

36

37. Net charge-offs on loans to finance agricultural production and other loans to farmers on or after 7/1/2010

37

38. Net charge-offs on loans secured by farmland on or after 7/1/2010

38

39. Subtotal (sum lines 35, 36, 37, and 38)

39

40. Dollar portion of net charge-offs on any such loans or group of such loans to the same borrower and its affiliates with an original principal or commitment
amount greater than $10 million
41. Dollar portion of net charge-offs on loans to businesses with more than $50 million in revenues, unless included in line 40
42. Dollar portion of net charge-offs on loans guaranteed by the U.S. government, unless included in line 40 or 41
43. Dollar portion of net charge-offs on loans where a third party has assumed an interest, unless included in line 40, 41, or 42
44. Total net charge-offs (line 44 equals line 39 minus lines 40, 41, 42, and 43)
45. Quarter-End Adjusted Qualified Small Business Lending (line 45 equals line 34 plus line 44)

40
41
42
43
44
45

Initial Supplemental Report for Banks
Treasury Department Form: TD F 102.3

5

OMB Number: 1505-0228

Initial Supplemental Report
for Banks Participating in the Small Business Lending Fund

Dividend Rate Calculation
Complete this section to determine the Dividend Rate for the quarter in which SBLF funding occurs only if the institution is not part
of a bank holding company. If the bank is controlled by a holding company, disregard this section.
Dollar amounts in thousands

Bil

Mil

Thou

46. Dollar value of funding from the Small Business Lending Fund
47. Dollar value of Initial Adjusted Small Business Lending Baseline (line 24)
48. Dollar value of Quarter-End Adjusted Qualified Small Business Lending (line 45)
49. Dollar value of increase in Qualified Small Business Lending from baseline (line 49 equals line 48 minus line 47)

46
47
48
49

50. Percent increase in Qualified Small Business Lending (line 50 equals line 49 divided by line 47)

50

%

51
52
53
54

$
%
$
5.0 %

55

%

Dividend Rates
51. If line 46 is greater than line 49, enter the amount from line 49; if line 49 is greater, enter the amount from line 46
52. Applicable Dividend Rate (from table in Instructions for Initial Supplemental Report) for amount in line 51
53. If line 46 is greater than line 49, enter the difference (line 46 minus line 49); otherwise, not applicable
54. Applicable Dividend Rate for amount in line 53, if needed
55. Weighted Average Dividend Rate for SBLF capital amount for the quarter in which funding occurs (must go out seven decimal points; see Instructions
for Initial Supplemental Report for details)

Please note that the information provided for the Dividend Rate Calculation and the name of the applicant institution
will be made available to the public when Treasury reports on bank participation in the Small Business Lending Fund.

Initial Supplemental Report for Banks
Treasury Department Form: TD F 102.3

6

OMB Number: 1505-0228