Application

Application Instructions
Applying to participate in the Small Business Lending Fund is easy.
To determine if your institution is eligible to participate in the Small Business Lending Fund (SBLF), please review the
eligibility criteria outlined in Chapter One of the Getting Started Guide for Community Banks, which can be found at
www.treasury.gov/SBLF.
If your institution is eligible and wants to apply, it must submit a completed version of the attached application to the
U.S. Department of the Treasury (Treasury) via email at [email protected]. Given processing times, applications
should be submitted by March 31, 2011.
Your institution must also submit a small business lending plan to its primary federal regulator and to its state regulator, if
applicable. If the institution is a holding company, the institution must also submit the lending plan to the primary federal
regulator (and state regulator, if applicable) of each of its insured depository institution subsidiaries.
The lending plan should not be sent directly to Treasury. (Your institution’s regulator will forward the plan to Treasury.)
Guidance and a form for an applicant's lending plan can be found at www.treasury.gov/SBLF.
If you have general questions about the application process, please call the Small Business Lending Fund information line at
888-832-1147 (Monday-Friday, 9:00 AM-7:00 PM ET).
For communications pertaining to a specific institution, please email [email protected], a confidential email
address.

Application
This application is for eligible institutions that are insured depository institutions or holding companies.
Name of Institution: _______________________________________________________
If the institution is a subsidiary of a bank holding company or of a savings and loan holding company, the holding company must apply.

FDIC Certificate Number, OTS Docket Number, or Federal Reserve RSSD Number: ___________________________
Address: ________________________________________________________________
Select State or Territory

City: _________________________ State: __ͺͺͺͺͺͺͺͺͺͺ____ͺͺͺͺͺͺ

Zipcode: ____________

Primary Contact Name: ____________________________________________________
Primary Contact Telephone: ________________________ Primary Contact Email: ____________________________
Asset Size:

$________________ (round to nearest thousand)

Asset size is the amount of total assets reported in the applicant’s Call Report as of the end of the fourth quarter of calendar year 2009. If the applicant is a
holding company, the question applies to the applicant’s total consolidated assets. Institutions and holding companies with assets of $10 billion or greater
are not eligible to participate in the Small Business Lending Fund.

Requested Investment Amount: $ ____________________________________________
The range of permissible amounts depends in part on whether the applicant’s asset size is greater than $1 billion.

CPP/CDCI Refinance?

___ Yes

___ No

If yes, list outstanding CPP/CDCI balance $___________________

Answer yes if the applicant will refinance an existing Capital Purchase Program or Community Development Capital Initiative investment with the SBLF funding.
If yes, specify the outstanding CPP/CDCI balance as of the date of this application.

Primary Federal Regulator of Insured Depository:

___ FDIC

___ OCC

___ OTS

___ Federal Reserve

If there are multiple insured depository institutions, please note all of the applicable primary federal and state regulators.

Is Applicant a Holding Company?

___ Yes

___ No

If yes, specify holding company regulator:
Is the Insured Depository State Chartered?

___ Federal Reserve

___ Yes

Small Business Lending Plan Sent to Regulator(s)

___ No

___ Yes

___ OTS
Select State or Territory

If yes, by which state? ____________________

___ No

Guidance and a form for an applicant's small business lending plan can be found at www.treasury.gov/SBLF.

Signature of Authorized Official: _____________________________________________
Name of Authorized Official: ________________________________________________
Title of Authorized Official: _________________________________________________
Date: __________________________________

OMB Number: 1505-0228