Supplemental Report

U .S. Department of the Treasury

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

Call Report used to complete: ______________________

This Quarterly Supplemental Report supplements the Consolidated Reports of Condition and Income (Call Reports) filed by a bank or 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) and the Chief Financial Officer (CFO) of the reporting bank or savings association (or by the individuals performing equivalent functions), and must be attested to by not fewer than two directors (trustees) for state nonmember banks and three directors for state member banks, national banks, and savings associations.

We, the undersigned CEO and CFO (or equivalents) of the named bank or 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.

Signature of CEO (or Equivalent)

Name Date

Signature of CFO (or Equivalent)

Name Date

Legal Title of Bank or Savings Association

City State Zip

SBLF#

0

RSSD#

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 Director (Trustee)

Name Date

Signature of Director (Trustee)

Name Date

Signature of Director (Trustee)

Name Date

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 Banks and 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 bank and 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 quarters until all SBLF securities have been redeemed. Please refer to the Instructions for the Quarterly Supplemental Report for Banks and Savings Associations Participating in the Small Business Lending Fund for guidance.

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-5:00 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 Banks and Savings Associations Participating in the Small Business Lending Fund

Quarter-End Adjusted Baseline Calculation

All banks and 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 Call Report with which the Quarterly Supplemental Report is being filed. For ease of use, lines pre-populated with zeros are automatically calculated and will not accept manual entry.

Dollar amounts in thousands		Bil	Mil	Thou
Initial Small Business Lending Baseline (line 12 in the Initial Supplemental Report)
	1
Prior quarter cumulative reported qualified small business lending increases resulting from an acquisition of, or merger with, another institution, and/or purchases of such loans as were reported on line 12 of the prior quarter's submitted Quarterly Supplemental Report
	2
Balance increases in commercial and industrial loans resulting from an acquisition of, or merger with, another institution, and/or purchases of such loans
	3
Balance increases in loans secured by owner-occupied nonfarm, nonresidential properties resulting from an acquisition of, or merger with, another institution, and/or purchases of such loans
	4
Balance increases in loans to finance agricultural production and other loans to farmers resulting from an acquisition of, or merger with, another institution, and/or purchases of such loans
	5
Balance increases in loans secured by farmland resulting from an acquisition of, or merger with, another institution, and/or purchases of such loans
	6
Subtotal (sum lines 3, 4, 5, and 6)
	7
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
	8
Dollar portion of such loans to businesses with more than $50 million in revenues, unless included in line 8
	9
Dollar portion of line 7 guaranteed by the U.S. government, unless included in lines 8 or 9
	10
Dollar portion of line 7 where a third party has assumed an interest, unless included in lines 8, 9, or 10
	11
Total cumulative reported qualified business lending increases resulting from an acquisition of, or merger with, another institution, and/or purchases of such loans (line 12 equals line 2 plus line 7 minus lines 8, 9, 10, and 11)
	12
Quarter-End Adjusted Small Business Lending Baseline (line 13 equals line 1 plus line 12)	13

Quarter-End Qualified Small Business Lending

All banks and 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 Call Report with which the Quarterly Supplemental Report is being filed. For ease of use, lines pre-populated with zeros are automatically calculated and will not accept manual entry.

	Quarter end
Dollar amounts in thousands		Bil	Mil		Thou
Balances of commercial and industrial loans (as reflected on Call Report Schedule RC-C, Part I, item 4)
	14
Balances of loans secured by owner-occupied nonfarm, nonresidential properties (as reflected on Call Report Schedule RC-C, Part I, item 1.e.(1))
	15
Balances of loans to finance agricultural production and other loans to farmers (as reflected on Call Report Schedule RC-C, Part I, item 3)
	16
Balances of loans secured by farmland (as reflected on Call Report Schedule RC-C, Part I, item 1.b)
	17
Subtotal (sum lines 14, 15, 16, and 17)
	18
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
	19
Dollar portion of such loans to businesses with more than $50 million in revenues, unless included in line 19
	20
Dollar portion of line 18 guaranteed by the U.S. government, unless included in lines 19 or 20
	21
Dollar portion of line 18 where a third party has assumed an interest, unless included in lines 19, 20, or 21
	22
Total quarter-end qualified small business loans (line 23 equals line 18 minus lines 19, 20, 21, and 22)	23

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

Net Charge-Off Adjustments

When completing this section, if net charge-offs are negative (i.e., recoveries exceed charge-offs), type a minus symbol (-) in the “Neg (-)” column that corresponds to that line. Amounts should reflect the net charge-offs reported on the Call Report filed for the same period as this Quarterly Supplemental Report. Charge-off amounts must be reported below as quarterly figures and not on a year-to-date basis. For ease of use, lines pre-populated with zeros are automatically calculated and will not accept manual entry.

	Net charge-offs
Dollar amounts in thousands		Neg (-)	Mil	Thou
Cumulative net charge-offs before this quarter (line 34 from prior quarter’s report)
	24
Net charge-offs on commercial and industrial loans
	25
Net charge-offs on loans secured by owner-occupied nonfarm, nonresidential properties
	26
Net charge-offs on loans to finance agricultural production and other loans to farmers
	27
Net charge-offs on loans secured by farmland
	28
Subtotal (sum lines 24, 25, 26, 27, and 28)
	29
Dollar portion of net charge-offs on any such loans or group of such loans (from lines 25, 26, 27, and 28) to the same borrower and its affiliates with an original principal or commitment amount greater than $10 million
	30
Dollar portion of net charge-offs on such loans (from lines 25, 26, 27, and 28) to businesses with more than $50 million in revenues, unless included in line 30
	31
Dollar portion of net charge-offs on loans (from lines 25, 26, 27, and 28) guaranteed by the U.S. government, unless included in line 30 or 31
	32
Dollar portion of net charge-offs on loans (from lines 25, 26, 27, and 28) where a third party has assumed an interest, unless included in line 30, 31, or 32
	33
Total cumulative net charge-offs (line 34 equals line 29 minus lines 30, 31, 32, and 33)	34
		Bil	Mil	Thou
Quarter-End Adjusted Qualified Small Business Lending (line 35 equals line 23 plus line 34)	35

Quarterly Supplemental Report
for Banks and 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. For ease of use, lines pre-populated with zeros are automatically calculated and will not accept manual entry.

		Bil	Mil	Thou	Hund
Dollar value of current balances with the Small Business Lending Fund	36
Dollar value of Quarter-End Adjusted Small Business Lending Baseline (line 13)	37				000
Dollar value of Quarter-End Adjusted Qualified Small Business Lending (line 35)	38				000
Dollar value of increase in Qualified Small Business Lending from baseline (line 39 equals line 38 minus line 37; if negative, enter 0 on line 39)	39				000
Percent increase in Qualified Small Business Lending (line 40 equals line 39 divided by line 37; must be calculated to two decimal points; if line 39 is 0, enter 0 on line 40)	40				%

Dividend or Interest Rates

For the 10^th 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 Interest Rate of 10.8%
(S-Corps and Mutuals) applies.

		Bil	Mil	Thou	Hund
If line 36 is greater than line 39 (i.e. the increase in lending is less than the current existing SBLF balance), enter the amount from line 39; if line 39 is greater (i.e. the increase in lending is greater than existing SBLF balance), enter the amount from line 36. If Line 39 is equal to 0 due to negative loan growth, then insert in line 41 the amount from line 36, insert in line 42 either 5% if a C-Corp or 7.7% if an S-Corp or Mutual, and leave lines 43, 44, and 45 blank.	41
Applicable Dividend or Interest Rate (from tables in the Instructions for Quarterly Supplemental Report) for amount in line 41. For the 8th quarter following the quarter in which funding occurred, if line 39 is equal to 0, then add 2% if a C-Corp or 3.1% if a S-Corp or Mutual to the rate in line 42.	42				%
		Bil	Mil	Thou	Hund
If line 36 is greater than line 39, enter the difference (line 36 minus line 39); otherwise, not applicable (if not applicable, leave lines 43, 44, and 45 blank)	43
Applicable Dividend or Interest Rate for amount in line 43 if needed	44				%
Weighted Average Dividend or Interest Rate for SBLF capital amount for the following quarter (must be calculated to seven decimal points; see Instructions for the Quarterly Supplemental Report for details)	45				%

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 and savings association participation in the Small Business Lending Fund.

Q uarterly Supplemental Report for Banks and Savings Associations 3

Treasury Department Form: TD F 102.4 (04/26/2012) v5 OMB Number: 1505-0228