Supplemental Report

U.S. Department of the Treasury

Quarterly Supplemental Report for Savings and Loan Holding Companies Participating in the Small Business Lending Fund
Subsidiaries’ Thrift Financial Report used to complete:___________________ (last day of calendar quarter)
This Quarterly Supplemental Report supplements the Thrift Financial Report (TFR) filed by the subsidiaries of a savings and loan 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 days after the end of the calendar quarter, and it must be signed by the Chief Executive Officer (CEO) and the Chief Financial
Officer (CFO) of the reporting savings and loan holding company (or by the individuals performing equivalent functions).
We, the undersigned CEO and CFO (or equivalents) of the named savings and loan 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

________________________________________________
Legal Title of Savings and Loan Holding Company
Select State
________________________________________________
City
State
Zip

_______________________________________________
Signature of Chief Financial Officer (or Equivalent)
_______________________________________________
Date of Signature

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 savings and loan holding company:
Institution Name
RSSD ID #
Institution Name
_______________________________________
______________
_________________________________________
_______________________________________
______________
_________________________________________
_______________________________________
______________
_________________________________________
_______________________________________
______________
_________________________________________
_______________________________________
______________
_________________________________________
_______________________________________
______________
_________________________________________

RSSD ID #
_____________
_____________
_____________
_____________
_____________
_____________

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

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OMB Number: 1505-0228

Quarterly Supplemental Report
for Savings and Loan 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 savings and loan 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 Savings and Loan Holding
Companies Participating in the Small Business Lending Fund for guidance.
The savings and loan holding company must also submit an Initial Supplemental Report, due no later than five (5) business days
before the closing date, as described in the separate Instructions for the Initial Supplemental Report for Savings and Loan 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 Savings and Loan Holding Companies
Treasury Department Form: TD F 102.4 (06/30/2011)

2

OMB Number: 1505-0228

Quarterly Supplemental Report
for Savings and Loan Holding Companies Participating in the Small Business Lending Fund

Quarter-End Adjusted Baseline Calculation
All savings and loan 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 aggregate information from the TFRs of each insured depository
institution for the applicable quarter.
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 in the quarter being reported
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 and loan 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 aggregate information from the TFRs of each insured depository institution
for the applicable quarter.
Quarter end
BIl
Mil

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

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
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)

15
16
17
18
19

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

Thou

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OMB Number: 1505-0228

Quarterly Supplemental Report
for Savings and Loan Holding Companies 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)
21. Net charge-offs on commercial loans: secured and unsecured

20
21

22. Net charge-offs on owner-occupied nonresidential property (except land) permanent loans
23. Subtotal (sum lines 20, 21, and 22)

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 and Loan Holding Companies
Treasury Department Form: TD F 102.4 (06/30/2011)

4

OMB Number: 1505-0228

Quarterly Supplemental Report
for Savings and Loan 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

Mil

Thou

Hund

30. Dollar value of funding from the Small Business Lending Fund
31. Dollar value of Quarter-End 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

000
000

33

000

34. Percent increase in Qualified Small Business Lending (line 40 equals line 33 divided by line 31)

34

%

Dividend or Interest Rates
th

For the 10 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) Žƌ ĂŶ/ŶƚĞƌĞƐƚZĂƚĞŽĨ10.8%
;^ͲŽƌƉƐĂŶĚMutuals) applies.
Bil

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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

38

%

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)

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 participation in the Small Business Lending Fund.

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

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OMB Number: 1505-0228