Supplemental Report

U.S. Department of the Treasury

Quarterly Supplemental Report for Bank Holding Companies Participating in the Small Business Lending Fund
Report at the close of business: _______________________ (last day of calendar quarter)
This Quarterly Supplemental Report supplements the Consolidated Reports of Condition and Income (Call Reports) and Thrift Financial Reports
(TFRs) filed by each insured depository institution subsidiary of a bank holding company 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 holding company (or by the individuals performing equivalent functions).
We, the undersigned CEO and CFO (or equivalents) of the named bank holding company, 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 Holding Company
Select State
________________________________________________
City
State
Zip

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
Please provide a listing of all insured depository institution subsidiaries of the bank holding company:
Institution Name
RSSD ID #
Institution Name
_______________________________________
______________
_________________________________________
_______________________________________
______________
_________________________________________
_______________________________________
______________
_________________________________________
_______________________________________
______________
_________________________________________
_______________________________________
______________
_________________________________________
_______________________________________
______________
_________________________________________

RSSD ID #
_____________
_____________
_____________
_____________
_____________
_____________

Quarterly Supplemental Report for Bank Holding Companies
Treasury Department Form: TD F 102.4 (06/30/2011)

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OMB Number: 1505-0228

Quarterly Supplemental Report
for Bank Holding Companies 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 bank holding company 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 Bank Holding Companies Participating in the
Small Business Lending Fund for guidance.
The bank holding company 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 Bank Holding Companies 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 Bank Holding Companies
Treasury Department Form: TD F 102.4 (06/30/2011)

2

OMB Number: 1505-0228

Quarterly Supplemental Report

for Bank Holding Companies Participating in the Small Business Lending Fund

Quarter-End Adjusted Baseline Calculation
All bank holding companies participating in the Small Business Lending Fund must complete this section. All figures are to be
reported in thousands of dollars. Amounts should reflect the aggregated information from the Call Reports and TFRs of each insured
depository institution for the applicable quarter.
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 (for banks) and commercial loans: secured and unsecured (for savings associations) 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 (for banks) and owner-occupied nonresidential property (except
land) permanent loans (for savings associations) 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 (for banks) resulting from an acquisition of or merger with another
institution and purchases of such loans
6. Balance increases in loans secured by farmland (for banks) 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
10. Dollar portion of line 7 guaranteed by the U.S. government, unless included in lines 8 or 9

8
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 bank holding companies participating in the Small Business Lending Fund must complete this section. All figures are to be reported in
thousands of dollars. Amounts should reflect the aggregated information from the Call Reports and TFRs of each insured depository
institution for the applicable quarter.
Dollar amounts in thousands
14. Combined balances of commercial and industrial loans (as reflected on the totals of Call Report Schedule RC-C, Part I, item 4) and commercial loans:
secured and unsecured (as reflected on the totals of TFR Schedule SC, items SC300 and SC303)
14
15. Combined balances of loans secured by owner-occupied nonfarm, nonresidential properties (as reflected on the totals of Call Report Schedule RC-C, Part I,
item 1.e.(1)) and owner-occupied nonresidential property (except land) permanent loans (as reflected on the totals of TFR Schedule LD, item LD530)
15
16. Balances of loans to finance agricultural production and other loans to farmers (as reflected on the totals of Call Report Schedule RC-C, Part I, item 3)
17. Balances of loans secured by farmland (as reflected on the totals of Call Report Schedule RC-C, Part I, item 1.b)
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
21. Dollar portion of line 18 guaranteed by the U.S. government, unless included in lines 19 or 20

16
17

19
20
21

22. Dollar portion of line 18 where a third party has assumed an interest, unless included in lines 19, 20, or 21

22
23

Quarterly Supplemental Report for Bank Holding Companies
Treasury Department Form: TD F 102.4 (06/30/2011)

Thou

18

19. Dollar portion of any loans or group of loans to the same borrower and its affiliates with an original principal or commitment amount greater than $10
million

23. Total quarter-end qualified small business loans (line 23 equals line 18 minus lines 19, 20, 21, and 22)

Quarter end
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OMB Number: 1505-0228

Quarterly Supplemental Report

for Bank Holding Companies 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 (for banks) and commercial loans: secured and unsecured (for savings associations)
26. Net charge-offs on loans secured by owner-occupied nonfarm, nonresidential properties (for banks) and owner-occupied nonresidential property (except
land) permanent loans (for savings associations)
27. Net charge-offs on loans to finance agricultural production and other loans to farmers (for banks)

26
27

28. Net charge-offs on loans secured by farmland (for banks)

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)

25

30
31
32
33
34
35

Quarterly Supplemental Report for Bank Holding Companies
Treasury Department Form: TD F 102.4 (06/30/2011)

4

OMB Number: 1505-0228

Quarterly Supplemental Report

for Bank Holding Companies 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.
Bil

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Thou

Hund

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; if negative, refer to the
Instructions for the Quarterly Supplemental Report)

36
37
38

000
000

39

000

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

40

%

Dividend or Interest 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% (C-Corps) or an Interest Rate of 10.8%
(S-Corps and Mutuals) applies.
Bil

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Hund

41. 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

41

42. Applicable Dividend or Interest Rate (from tables in Instructions for Quarterly Supplemental Report) for amount in line 41

42

43. If line 36 is greater than line 39, enter the difference (line 36 minus line 39); otherwise, not applicable

43

44. Applicable Dividend or Interest Rate for amount in line 43, if needed
45. 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)

44

%

45

%

%
Bil

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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 bank participation in the Small Business Lending Fund.

Quarterly Supplemental Report for Bank Holding Companies
Treasury Department Form: TD F 102.4 (06/30/2011)

5

OMB Number: 1505-0228