Form TD F 102.1 TD F 102.1 Dividend Inquiry Report

Inquiry Regarding Dividend Payments

The U.S. Department of the Treasury is currently processing your institution’s application to the Small Business Lending Fund (SBLF) and requires additional information to proceed with our evaluation.

Applicants must be able to pay dividends on securities issued to Treasury upon entry into the Fund as a requirement of participation. Payment of dividends on SBLF securities must not be subject to approval by any third party, including a governmental entity. This requirement includes restrictions imposed as a result of federal or state supervisory enforcement actions (such as a memorandum of understanding, cease and desist order, or board resolution) or federal or state laws or regulations.

If any such restrictions imposed by federal or state governmental entities apply to your institution, they must be removed or waived before Treasury can continue to process your institution’s application.

Your prompt attention to this matter is appreciated. In the boxes below, please indicate whether your institution is able to pay dividends on its SBLF funding. Please return this form within five (5) business days of receipt to [email protected].

Name of Applicant (Required):

Federal Reserve RSSD Number (Required):

M y institution is able to pay dividends on SBLF securities.

M y institution is unable to pay dividends on SBLF securities for the reasons described below, and will attempt to have dividend restrictions imposed by any federal or state governmental entities removed or waived. Please note that all such restrictions must be removed or waived and a new form must be filed by August 1 for an institution to qualify for participation in the Small Business Lending Fund.

M y institution is unable to pay dividends on SBLF securities and does not plan to request the removal or waiver of these restrictions.

Please include any additional information regarding these restrictions below, if applicable. If your institution is a bank or thrift holding company that controls one or more insured depository institution subsidiaries, please note whether these subsidiaries are subject to separate restrictions with respect to dividend payments.

I attest that the information on this form is true and accurate to the best of my knowledge and belief.

­­­­­­­­­­­­­­­­_______________________________ __ /__ /__ _____________________________________

Name / Title of Authorized Official Date Signature

Please note that this correspondence should not be construed as an
indication of Treasury’s approval of your institution’s application.

Paperwork Reduction Act Statement: 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. Treasury Department Form: TD F 102.1 (05/16/11) OMB Number: 1505-0228