Form FR G-3 FR G-3 Statement of Purpose for an Extension of Credit Secured

FR G-3
OMB Number 7100-0018
Approval expires January 31, 2018
Page 1 of 2

Board of Governors of the Federal Reserve System

Statement of Purpose for an Extension of Credit Secured by
Margin Stock by a Person Subject to Registration Under
Regulation U—FR G-3
Name of Lender

This form is required by law (15 U.S.C. §§ 78g and 78w; 12 C.F.R.
§ 221).

The Federal Reserve may not conduct or sponsor, and an organization (or a person) is not required to respond to, a collection of
information unless it displays a currently valid OMB control number.

Instructions
1. This form must be completed when a lender subject to registration under Regulation U extends credit secured directly or indirectly, in
whole or in part, by any margin stock.
2. The term “margin stock” is defined in Regulation U (12 C.F.R. § 221) and includes, principally: (1) stocks that are registered on a
national securities exchange or any OTC security designated for trading in the National Market System; (2) debt securities (bonds)
that are convertible into margin stock; and (3) shares of most mutual funds.
3. Please print or type (if space is inadequate, attach separate sheet).

Part I
To be completed by borrower(s)
1. What is the amount of the credit being extended?
2. Will any part of this credit be used to purchase or carry margin securities?

Yes

No

If the answer is "No," describe the specific purpose of the credit.

I (We) have read this form and certify that to the best of my (our) knowledge and belief the information given is true, accurate, and
complete.
Signed:

Signed:

Borrower's Signature

Print or Type Name

Date

Borrower's Signature

Date

Print or Type Name

This form should not be signed if blank.
A borrower who falsely certifies the purpose of a credit on this form or otherwise willfully or intentionally evades
the provisions of Regulation U will also violate Federal Reserve Regulation X, “Borrowers of Securities Credit.”
Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time to gather and maintain data in the required form and to review
instructions and complete the information collection. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden to: Secretary, Board of Governors of the Federal Reserve System, 20th and C Streets, NW, Washington, DC 20551; and to the Office of Management and Budget, Paperwork
Reduction Project (7100-0018), Washington, DC 20503.
01/2015

FR G-3
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Part II
To be completed by lender only if the purpose of the credit is to purchase or carry margin securities (if Part 1 (2) is answered "Yes").
1. List the margin stock securing this credit; do not include debt securities convertible into margin stock. The maximum loan value of
margin stock is 50 percent of its current market value under the current Supplement to Regulation U.

No. of shares

Market price
per share

Issue

Date and source
of valuation
(See note below)

Total market
value per issue

2. List the debt securities convertible into margin stock securing this credit. The maximum loan value of such debt securities is 50
percent of the current market value under the current Supplement to Regulation U.

Principal
amount

Issue

Market price

Date and source
of valuation
(See note below)

Total market
value per issue

Market price

Date and source
of valuation
(See note below)

Good faith
loan value

3. List other collateral, including non-margin securities, securing this credit.

Describe briefly

NOTE: Lender need not complete "Date and source of valuation" if the market value was obtained from regularly published information in a journal of
general circulation or automated quotation system.

Part III
To be signed by an authorized representative of the lender in all instances
I am a duly authorized representative of the lender and understand that this credit secured by margin stock may be subject to the credit
restrictions of Regulation U. I have read this form and any attachments, and I have accepted the customer’s statement in Part I in good
faith as required by Regulation U.* I certify that to the best of my knowledge and belief, all the information given is true, accurate, and
complete. I also certify that if any securities that directly secure the credit are not or will not be registered in the name of the borrower or
its nominee, I have or will cause to have examined the written consent of the registered owner to pledge such securities.
Signed:

Authorized Representative's Signature

Date

Print or Type Name

Title

To accept the customer’s statement in good faith, the authorized representative of the lender must be alert to the circumstances surrounding the credit
*and,
if in possession of any information that would cause a prudent person not to accept the statement without inquiry, must have investigated and be satisfied that the statement is truthful. Among the facts which would require such investigation are receipt of the statement through the mail or from a third party.

This form must be retained by the lender for three years after the credit is extinguished.
01/2011