Supplemental Report

U.S. Department of the Treasury

Quarterly Supplemental Report for Banks Participating in the Small Business Lending Fund
Call Report used to complete: _______________________ (last day of calendar quarter)
This Quarterly Supplemental Report supplements the Report of Condition and Income filed by a bank that has received capital from the U.S.
Department of the Treasury (Treasury) through the Small Business Lending Fund. This Quarterly Supplemental Report must be filed no more than
30 calendar days after the end of the calendar quarter, 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 not 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 Quarterly 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
Quarterly Supplemental Report for this report date and declare that the
Quarterly 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 Quarterly 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:
Wire Information SBLF Institutions Should Use to Make Dividend or Interest Payments to Treasury:
Bank Name:
ABA (Routing) Number:
BNF Acct Name:
BNF Acct Number:
REF:

The Bank of New York Mellon
021000018
Income Collection
111566
Private Placements – SBJA
Security Name & Cusip

Quarterly Supplemental Report for Banks
Treasury Department Form: TD F 102.4

1

OMB Number: 1505-0228

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

Table of Contents
Quarter-End Adjusted Baseline Calculation
Quarter-End Qualified Small Business Lending
Dividend Rate Calculation
Every bank participating in the Small Business Lending Fund (SBLF) is required to submit a Quarterly Supplemental Report no more
than 30 calendar days after the quarter in which SBLF funding is received and in each of the following nine quarters. Please refer
to the Instructions for the Quarterly Supplemental Report for Banks Participating in the Small Business Lending Fund for guidance.
The bank must also submit an Initial Supplemental Report, within five business days prior to the closing date, as described in the
separate Instructions for the Initial 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.

Quarterly Supplemental Report for Banks
Treasury Department Form: TD F 102.4

2

OMB Number: 1505-0228

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

Quarter-End Adjusted Baseline Calculation
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 on the Call Report with which the Quarterly Supplemental Report is being filed.

Bil

Dollar amounts in thousands
1. Initial Small Business Lending Baseline (line 12 in the Initial Supplemental Report)

Mil

Thou

1

2. Prior quarter cumulative reported qualified small business lending increases resulting from an acquisition of, or merger with, another institution, and
purchases of such loans (see instructions for line reference information)
3. Balance increases in commercial and industrial loans resulting from an acquisition of, or merger with, another institution, and purchases
of such loans
4. 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
5. 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
6. Balance increases in loans secured by farmland resulting from an acquisition of, or merger with, another institution, and purchases of such loans
7. Subtotal (sum lines 3, 4, 5, and 6)

2
3
4
5
6
7

8. 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
9. Dollar portion of such loans to businesses with more than $50 million in revenues, unless included in line 8

8
9

10. Dollar portion of line 7 guaranteed by the U.S. government, unless included in lines 8 or 9

10

11. Dollar portion of line 7 where a third party has assumed an interest, unless included in lines 8, 9, or 10

11

12. Total cumulative reported qualified business lending increases resulting from an acquisition of, or merger with, another institution, and purchases of such
loans (line 12 equals line 2 plus line 7 minus lines 8, 9, 10, and 11)
13. Quarter-End Adjusted Small Business Lending Baseline (line 13 equals line 1 plus line 12)

12
13

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 on the Call Report with which the Quarterly Supplemental Report is being filed.
Quarter end
Bil
Mil

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

14

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

22. Dollar portion of line 18 where a third party has assumed an interest, unless included in lines 19, 20, or 21
23. Total quarter-end qualified small business loans (line 23 equals line 18 minus lines 19, 20, 21, and 22)

16

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

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

15

17

18. Subtotal (sum lines 14, 15, 16, and 17)

20. Dollar portion of such loans to businesses with more than $50 million in revenues, unless included in line 19

19
20
21
22
23

Quarterly Supplemental Report for Banks
Treasury Department Form: TD F 102.4

Thou

3

OMB Number: 1505-0228

Quarterly Supplemental Report
for Banks Participating in the Small Business Lending Fund
Net Charge-Off Adjustments
Net charge-offs
Bil
Mil
Thou

Dollar amounts in thousands
24. Net charge-offs from prior quarter's report (see instructions for line reference information)

24

25. Net charge-offs on commercial and industrial loans

25

26. Net charge-offs on loans secured by owner-occupied nonfarm nonresidential properties

26

27. Net charge-offs on loans to finance agricultural production and other loans to farmers

27

28. Net charge-offs on loans secured by farmland

28

29. Subtotal (sum lines 24, 25, 26, 27, and 28)

29

30. 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
31. Dollar portion of net charge-offs on such loans to businesses with more than $50 million in revenues, unless included in line 30
32. Dollar portion of net charge-offs on loans guaranteed by the U.S. government, unless included in line 30 or 31
33. Dollar portion of net charge-offs on loans where a third party has assumed an interest, unless included in line 30, 31, or 32
34. Total cumulative net charge-offs (line 34 equals line 29 minus lines 30, 31, 32, and 33)
35. Quarter-End Adjusted Qualified Small Business Lending (line 35 equals line 23 plus line 34)

30
31
32
33
34
35

Quarterly Supplemental Report for Banks
Treasury Department Form: TD F 102.4

4

OMB Number: 1505-0228

Quarterly 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 immediately following the quarter in which the report is filed only
if the institution is not part of a bank holding company. If the institution is a part of a bank holding company, disregard this section.
Dollar amounts in thousands

Bil

36. Dollar value of funding from the Small Business Lending Fund
37. Dollar value of Quarter-End Adjusted Small Business Lending Baseline (line 13)
38. Dollar value of Quarter-End Adjusted Qualified Small Business Lending (line 35)
39. Dollar value of increase in Qualified Small Business Lending from baseline (line 39 equals line 38 minus line 37)

36
37
38
39

40. Percent increase in Qualified Small Business Lending (line 40 equals line 39 divided by line 37)

40

Mil

Thou

%

Dividend Rates
For the 10th quarter following the quarter in which funding occurred, if line 40 is greater than zero, the rate calculated in line 45 applies
until four-and-one-half years following funding. Otherwise, a Dividend Rate of 7% applies.
41.
42.
43.
44.
45.

If line 36 is greater than line 39, enter the amount from line 39; if line 39 is greater, enter the amount from line 36
Applicable Dividend Rate (from tables in Instructions for Quarterly Supplemental Report) for amount in line 41
If line 36 is greater than line 39, enter the difference (line 36 minus line 39); otherwise, not applicable
Applicable Dividend Rate for amount in line 43, if needed
Weighted Average Dividend Rate for SBLF capital amount for the following quarter (must go out seven decimal points; see instructions for details)

41
42
43
44
45

$
%
$
5.0 %
%

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.

Quarterly Supplemental Report for Banks
Treasury Department Form: TD F 102.4

5

OMB Number: 1505-0228