SHLA -- Schedule 1 SHLA -- Schedule 1, Schedule 2

Department of the Treasury

OMB No. 1505-0123

Approval Expires 12/31/2017

Report of Foreign Holdings of U.S. Securities, Including Selected Money Market Instruments
(SHL(A))
SCHEDULE 1: REPORTER CONTACT IDENTIFICATION AND
SUMMARY OF FINANCIAL INFORMATION

1.

Reporter Identification Number (RSSD): …………………………………………….

2.

Organization Name:

.

3. Street Address:

4. City:

5. State:

6. Zip Code:

7. Reporting Status:……………………………………..……..……………………………………………………………….
1 = Exempt - Under the exemption level
2 = Not Exempt - Schedule 2 records being submitted

8. Reporter Type:……………………..…………………………………………….……………….……….…………………
1 = Depository Institution
2 = Fund/Fund Manager/Sponsor
(excluding pension fund)
3 = Pension Fund

4 = Insurance Company
5 = Other Financial Organization
(including BHC, FHC, broker/dealers)
6 = Non-financial Organization

7 = Foundation, trust, estate
8 = Institution of higher learning
(e.g., university)
9 = Other (not listed above)

If you would like to provide more than one contact name, please attach additional copies of page 1, Schedule 1, with items 9
through 13 completed.
Business Contact Information:
9.

Name: __________________________________________________________________________________

10. Title:

__________________________________________________________________________________

11. Telephone Number: ____________________________
12. Email Address: ____________________________________________________________________________
13. Name of Service Provider or Vendor Used (if applicable): ___________________________________________
Technical Contact Information:
14. Name: __________________________________ 15. Title: ___________________________________________
16. Telephone Number: ______________________ 17. Email Address: ___________________________________

SHL(A)

Schedule 1, Page 1 of 3

Department of the Treasury

OMB No. 1505-0123

Approval Expires 12/31/2017

Reporter Identification Number (RSSD):...……………………………………………….
18. Valuation Technique(s) Used to Determine Fair Values
For each reporting unit, please describe the valuation technique(s) used to determine reported fair values. If securities are
automatically valued at zero after a specified time period of inactivity, please specify the time period and whether this applies
to the security or to the client’s holdings of the security. Also, please specify how securities not actively traded on the report
date and those with internally generated security identification numbers are valued.
Reporting Unit

SHL(A)

Valuation Description

Schedule 1, Page 2 of 3

Department of the Treasury

OMB No. 1505-0123

Approval Expires 12/31/2017

Reporter Identification Number (RSSD)…………………………………………...……..
SUMMARY OF SCHEDULE 2 INFORMATION
19. Total Number of Schedule 2s Submitted……………………….……………………………..

,

,

20. Total US$ Fair Value of All Equity Securities ……………….
Reported on Schedule 2(s)

,

,

,

,

21. Total US$ Fair Value of All Short-Term Debt Securities…
(excluding asset-backed securities) Reported on Schedule 2(s)

,

,

,

,

22. Total US$ Fair Value of All Long-Term Debt Securities….
(excluding asset-backed securities) Reported on Schedule 2(s)

,

,

,

,

23. Total US$ Fair Value of All Asset-Backed……………….
Securities Reported on Schedule 2(s)

,

,

,

,

CERTIFICATION INFORMATION
By signing the certification below you acknowledge that:




You have read and understood the reporting requirements of this report;
You are aware that both civil and criminal penalties may be imposed for filing a false report; and
You are sufficiently knowledgeable about the activities and functions of your organization that you can knowingly and
with reasonable confidence certify that the information provided in this report is both accurate and complete.

Certifier's Signature:

24. Date Signed:

25. Certifier's Name:
26. Certifier's Title:
27. Certifier's Telephone Number:
28. Certifier's Email Address:

SHL(A)

Schedule 1, Page 3 of 3

Department of the Treasury

OMB No. 1505-0123

Approval Expires 12/31/2017

SCHEDULE 2: DETAILS OF SECURITIES
1.

Reporter Identification Number (RSSD):……………….……………………..…………

2.

Sequence Number: …………………………………………………………………………..…… , ,

3.

Reporting Unit:……………………………………………………………..………….………….…………..………..

4.

Name of Reporting Unit: ____________________________________________________________________________

, ,

5. Reporting As: …………………………………………………………………………………………………………...…
1 = Issuer

2 = Custodian

6. Security ID…………………………………………………………………………
7. Security ID System: ………………………………….………………………………………………………………..…..
1 = CUSIP
2 = ISIN
6 = Internally Generated

3 = CINS
4 = Common Code
7 = Other (provide answer to 8)

5 = SEDOL

8. For code of Other (7) enter the name of the organization or system that assigned the Security ID:

9. Security Description:
10. Name of Issuer:
11. Type of Issuer: ……………………………………………………………………………………………………………
1 = United States Treasury and Federal Financing Bank
2 = Federal agency or federally sponsored enterprise
3 = State or local government, including their subdivisions

4 = Depository institution
5 = Other financial organization (including BHC, FHC, broker/dealer)
6 = Nonfinancial organization

12. Security Type: …………………………………..……………………………………………………………………
Equities

Debt (excluding asset-backed securities)

1 = Common stock
2 = Preferred stock
3 = Fund shares
4 = All other equity

5 = Commercial paper
6 = Negotiable CD
7 = Convertible debt security
8 = Zero-coupon bond or note

9 = Bond or note, unstripped
10 = Bond or note, stripped
11 = All other debt

Asset-Backed Securities
12 = Asset-backed security

13. Country of Residence of Foreign Holder: (Refer to Appendix C)………………………………………

…… …

…

14. Currency of Denomination: (Refer to Appendix E)……………………………………………………………… …. …….
15. Type of Foreign Holder: (Refer to Appendix C and D) ……………………………………………………………..…..
1 = Official

SHL(A)

2 = Other

Schedule 2, Page 1 of 2

Department of the Treasury

OMB No. 1505-0123

Approval Expires 12/31/2017

Reporter Identification Number (RSSD): …………………………………………….………

16. US$ Fair Value of Security:….………………….………………………… …

,

… ,

17. Fair Value of Security in the Currency of Denomination:……………………

,

,

,

,

,

,

,

FOR EQUITIES ONLY
(Security Types 1, 2, 3 or 4)
18. Number of Shares:………………………………………………………….….

FOR ALL DEBT SECURITIES
(NON-ASSET-BACKED AND ASSET-BACKED SECURITIES)
(Security Types 5, 6, 7, 8, 9, 10, 11, or 12)
19. Face Value (for non-ABS) or Remaining Principal Outstanding (for ABS)
in the Currency of Denomination: ……………….…………………..…

,

,

, ,

,

,

,

,

FOR ASSET-BACKED SECURITIES ONLY
(Security Type 12)
20.

Original Face Value in the Currency of Denomination: ……………….……..

FOR ALL DEBT SECURITIES
(NON-ASSET-BACKED AND ASSET-BACKED SECURITIES)
(Security Types 5, 6, 7, 8, 9, 10, 11, or 12)
21.

Issue Date: (MMDDYYYY)……………………………………………………………………

22.

Maturity Date: (MMDDYYYY)…………………….………………………………………….

SHL(A)

Schedule 2, Page 2 of 2

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