Supplemental Report

U.S. Department of the Treasury

Quarterly Supplemental Report for Savings Associations Participating in the Small Business Lending Fund
Call Report used to complete: ________________________ (last day of calendar quarter)
This Quarterly Supplemental Report supplements the Thrift Financial Report (TFR) filed by a savings association 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) (or an individual performing the
equivalent function) and by the authorized officer who signs the TFR of the reporting savings association; and must be attested to by no fewer than
three directors (trustees).
We, the undersigned CEO and authorized officer of the named savings
association, 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.

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.

_______________________________________________
Signature of Chief Executive Officer (or Equivalent)
_______________________________________________
Date of Signature
_______________________________________________
Name and Title of Officer Authorized to Sign TFR
_______________________________________________
Signature of Officer Authorized to Sign TFR
_______________________________________________
Date of Signature
_______________________________________________
Legal Title of Savings Association
Select State
_________________________________________________
City
State
Zip

________________________________________________
Director (Trustee)
________________________________________________
Director (Trustee)
________________________________________________
Director (Trustee)

SBLF #
RSSD ID # ______________________________________________

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.

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
Quarterly Supplemental Report for Savings Associations
Treasury Department Form: TD F 102.4 (06/30/2011)

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OMB Number: 1505-0228

Quarterly Supplemental Report
for Savings Associations Participating in the Small Business Lending Fund
Table of Contents
Quarter-End Adjusted Baseline Calculation
Quarter-End Qualified Small Business Lending
Dividend or Interest Rate Calculation
Every savings association 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 (9)
quarters. Please refer to the Instructions for the Quarterly Supplemental Report for Savings Associations Participating in the Small
Business Lending Fund for guidance.
The savings association must also submit an Initial Supplemental Report, no later than five (5) business days before the closing date,
as described in the separate Instructions for the Initial Supplemental Report for Savings Association 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 Savings Associations
Treasury Department Form: TD F 102.4 (06/30/2011)

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OMB Number: 1505-0228

Quarterly Supplemental Report
for Savings Associations Participating in the Small Business Lending Fund

Quarter-End Adjusted Baseline Calculation
All savings associations 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 TFR with which the Quarterly Supplemental Report is being filed.
Bil

Dollar amounts in thousands
1. Initial Small Business Lending Baseline (line 10 of 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 loans: secured and unsecured resulting from an acquisition of, or merger with, another institution, and purchases of such
loans
4. Balance increases in owner-occupied nonresidential property (except land) permanent loans resulting from an acquisition of, or merger with, another
institution, and purchases of such loans
5. Subtotal (sum lines 3-4)

2
3
4
5

6. Dollar portion of any such loan 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

6
7

8. Dollar portion of line 5 guaranteed by the U.S. government, unless included in lines 6 or 7

8

9. Dollar portion of line 5 where a third party has assumed an interest, unless included in lines 6, 7, or 8

9

10. Total cumulative reported qualified business lending increases resulting from an acquisition of, or merger with, another institution, and purchases of such
loans (line 10 equals line 2 plus line 5 minus lines 6, 7, 8, and 9)
11. Quarter-End Adjusted Small Business Lending Baseline (line 11 equals line 1 plus line 10)

10
11

Quarter-End Qualified Small Business Lending
All savings associations 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 TFR with which the Quarterly Supplemental Report is being filed.
Quarter end
BIl
Mil

Dollar amount in thousands
12. Balances of commercial loans: secured and unsecured (as reflected on TFR Schedule SC, items SC300 and SC303)
13. Balances of owner-occupied nonresidential property (except land) permanent loans (as reflected on TFR Schedule LD, item LD530)
14. Subtotal (sum lines 12-13)

17. Dollar portion of line 14 guaranteed by the U.S. government, unless included in lines 15 or 16
18. Dollar portion of line 14 where a third party has assumed an interest, unless included in lines 15, 16, or 17

19. Total quarter-end qualified small business loans (line 19 equals line 14 minus lines 15, 16, 17, and 18)

12
13
14

15. Dollar portion of any such loan or group of such loans to the same borrower and its affiliates with an original principal or commitment amount
greater than $10 million
16. Dollar portion of such loans to businesses with more than $50 million in revenues, unless included in line 15

15
16
17
18

19

Quarterly Supplemental Report for Savings Associations
Treasury Department Form: TD F 102.4 (06/30/2011)

Thou

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OMB Number: 1505-0228

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

Dollar amount in thousands
20. Net charge-offs from prior quarter’s report (see instructions for line reference information)

20

21. Net charge-offs on commercial loans: secured and unsecured

21

22. Net charge-offs on owner-occupied nonresidential property (except land) permanent loans

22

23. Subtotal (sum lines 20, 21, and 22)

23

24. Dollar portion of net charge-offs on any such loan or group of such loans to the same borrower and its affiliates with an original principal or commitment
amount greater than $10 million
25. Dollar portion of net charge-offs on such loans to businesses with more than $50 million in revenues, unless included in line 24
26. Dollar portion of net charge-offs on loans guaranteed by the U.S. government, unless included in lines 24 or 25
27. Dollar portion of net charge-offs on loans where a third party has assumed an interest, unless included in lines 24, 25, or 26
28. Total cumulative net charge-offs (line 28 equals line 23 minus lines 24, 25, 26, and 27)
29. Quarter-End Adjusted Qualified Small Business Lending (line 29 equals line 19 plus line 28)

24
25
26
27
28
29

Quarterly Supplemental Report for Savings Associations
Treasury Department Form: TD F 102.4 (06/30/2011)

4

OMB Number: 1505-0228

Quarterly Supplemental Report
for Savings Associations Participating in the Small Business Lending Fund

Dividend or Interest Rate Calculation

Complete this section to determine the Dividend or Interest Rate for the quarter immediately following the quarter in which the report is
filed only if the savings association is not controlled by a holding company. If the savings association is controlled by a holding company,
disregard this section.
Bil
30. Dollar value of funding from the Small Business Lending Fund
31. Dollar value of Initial Adjusted Small Business Lending Baseline (line 11)
32. Dollar value of Quarter-End Adjusted Qualified Small Business Lending (line 29)
33. Dollar value of increase in Qualified Small Business Lending from baseline (line 33 equals line 32 minus line 31; if negative, refer to the
Instructions for the Quarterly Supplemental Report)

30
31
32

34. Percent increase in Qualified Small Business Lending (line 34 equals line 33 divided by line 31)

34

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Thou

Hund
000
000
000

33
%

Dividend or Interest Rates
For the 10th quarter following the quarter in which funding occurred, if line 34 is greater than zero, the rate calculated in line 39
applies until four-and-one-half years following funding. Otherwise, a Dividend Rate of 7% (C-Corps) or an Interest Rate of 10.8%
(S-Corps and Mutuals) applies.
Bil

Mil

Thou

Hund

35. If line 30 is greater than line 33, enter the amount from line 33; if line 33 is greater, enter the amount from line 30

35

36. Applicable Dividend or Interest Rate (from tables in the Instructions for the Quarterly Supplemental Report) for amount in line 35

36

37. If line 30 is greater than line 33, enter the difference (line 30 minus line 33); otherwise, not applicable

37

38. Applicable Dividend or Interest Rate for amount in line 37, if needed
39. Weighted Average Dividend or Interest Rate for SBLF capital amount for the following quarter (must go out seven decimal points; see
Instructions for the Quarterly Supplemental Report for details)

38

%

39

%

%
Bil

Mil

Thou

Hund

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

Quarterly Supplemental Report for Savings Associations
Treasury Department Form: TD F 102.4 (06/30/2011)

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OMB Number: 1505-0228