Form FR Y-12A FR Y-12A Annual Report of Merchant Banking Investments Held for a

FR Y-12A
OMB Number 7100–0300
Avg. hrs. per response: 7.00
Expires December 2012

Board of Governors of the Federal Reserve System

Annual Report of Merchant Banking Investments
Held for an Extended Period—FR Y-12A
Cover Page

Report Date

(MM/DD/YYYY) (FHMB 9999)

Reporter's Name, Street, and Mailing Address
Legal Name (RSSD 9010)

Street Address (RSSD 9028)

Reporter's Mailing Address (if different from street address) (FHMB 9110)

City/County (RSSD 9130)

Mailing City (FHMB F206)

State/Province, Country (RSSD 9200)

Zip/Postal Code (RSSD 9220)

Mailing State/Province, Country (FHMB F207)

Zip/Postal Code (FHMB F208)

Contact's Name and Mailing Address for this Report

Name and Title (FHMB 8901)

Contact's Mailing Address (if different from above) (FHMB 9185)

Phone Number (Include area code and if applicable, the extension) (FHMB 8902)

Mailing City (FHMB 9187)

Fax Number (Include area code) (FHMB 9116)

Mailing State/Province, Country (FHMB F209)

Zip/Postal Code (FHMB 9189)

E-mail Address (FHMB 4086)

Executive Officer
I,

,
Printed Name (FHMB C490)

,
Title (FHMB C491)

am an authorized officer of the company named above, and
hereby declare that this report is true and complete to the best of
my knowledge and belief.

Signature of Executive Officer

For Federal Reserve Bank Use Only

Date of Signature

Public reporting burden for this information collection is estimated to average
7 hours per response, including time to gather and maintain data in the required
form and to review instructions and complete the information collection. Comments
regarding this burden estimate or any other aspect of this information collection,
including suggestions for reducing the burden, may be sent to Secretary, Board of
Governors of the Federal Reserve System, Washington, D.C. 20551, and to the
Office of Management and Budget, Paperwork Reduction Project (7100–0300),
Washington, D.C. 20503.

BHC RSSD ID
SUB RSSD ID

This report is required by law: Sections 4(k)(4)(H) and 5(c) of the Bank Holding
Company Act (BHC Act) (12 U.S.C. 1843(k)(4)(H) and 1844 (c)) and subpart J of the
Board's Regualtion Y (12 CFR 225.170 et seq.).

FR Y–12A
Page 1

Annual Report of Merchant Banking Investments Held
for an Extended Period (FR Y-12A)

For Federal Reserve Bank Use Only
BHC RSSD ID
SUB RSSD ID

Direct Holder's Name and Location
Legal Name (FHMB F189)

City/County (FHMB F190)

State/Province, Country (FHMB F191)

Zip/Postal Code (FHMB F192)

State/Province, Country (FHMB F196)

Zip/Postal Code (FHMB F197)

Covered Investment Section
1. Acquisition Date of Covered Investment:
(MM/DD/YYYY) (FHMB F193)

2. Name and Location of Company Held:
Legal Name (FHMB F194)

City/County (FHMB F195)

3. Primary Activity of Company Held:
NAICS
Activity Code
Description of Activity (if no Activity Code applicable)
(FHMB F198)

(FHMB F199)

4. Type of Interest held by Financial Holding Company:
Common Stock
Preferred Stock
(FHMB F200)

Warrants

General Partner
(FHM2 F200)

(FHM1 F200)

Options

(FHM4 F200)

(FHM5 F200)

Limited Partner
(FHM3 F200)

Convertible Debt
(FHM6 F200)

Other
(FHM7 F200)

If other, please describe:
(FHM8 F200)

5. Percentage of Ownership held by Financial Holding Company:
% Voting Equity
(FHMB F201)

% Nonvoting Equity
(FHMB F202)

6. Acquisition Cost of the Covered Investment: $

(in millions of U.S. dollars)
(FHMB F203)

7. Carrying Value of the Covered Investment: $

(in millions of U.S. dollars)
(FHMB F204)

8. Plan and Schedule for disposition of the Covered Investment:
(FHMB F205)
(FHM1 F205)
(FHM2 F205)
(FHM3 F205)
(FHM4 F205)
(FHM5 F205)
(FHM6 F205)
(FHM7 F205)
(FHM8 F205)

06/06