Form FR Y-12A FR Y-12A Annual Report of Merchant Banking Investments Held for a

FR Y-12A
OMB Number 7100-0300
Approval expires December 31, 2018
Page 1 of 2

Board of Governors of the Federal Reserve System

Annual Report of Merchant Banking Investments
Held for an Extended Period—FR Y-12A
This report is required by law: Section 5(c) of the BHC Act
(12 U.S.C. § 1844(c)), section 10 of HOLA (12 U.S.C.
§ 1467a(b)), section 165 of the Dodd-Frank Act (12 U.S.C. §
5365), and section 252.153(b)(2) of Regulation YY (12 CFR
252.153(b)(2)).

The Annual Report of Merchant Banking Investments Held for an
Extended Period is to be prepared in accordance with the instructions provided by the Federal Reserve System. 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.

Reporter's Name, Street, and Mailing Address

Date of Report:
Month / Day / Year (FHMB 9999)

Legal Name of Reporter (RSSD 9010)

Physical Street Address (RSSD 9028)

Reporter's Address (if different from physical street address) (FHMB 9110)

City and County (RSSD 9130)

City (FHMB F206)

State / Province, Country (RSSD 9200)

Zip / Postal Code (RSSD 9220)

State / Province, Country (FHMB F207)

Zip / Postal Code (FHMB F208)

Contact's Name and Mailing Address for this Report
Name and Title (FHMB 8901)

Contact's Address (if different from reporter's) (FHMB 9185)

Area Code / Phone Number / Extension (FHMB 8902)

City (FHMB 9187)

Area Code / FAX Number (FHMB 9116)

State / Province, Country (FHMB F209)

Zip / Postal Code (FHMB 9189)

E-mail Address (FHMB 4086)

NOTE: The Annual Report of Merchant Banking Investments Held for an Extended Period must be signed and attested by an
authorized officer of the reporting company.

I,

,
Printed Name of Executive Officer (FHMB C490)

Title of Executive Officer (FHMB C491)

attest that the Annual Report of Merchant Banking Investments Held for an Extended Period for this report date has been prepared in
conformance with the instructions issued by the Federal Reserve System and is true and correct to the best of my knowledge and belief.

Signature of Executive Officer (FHMB H321)

Date of Signature (MM/DD/YYYY) (FHMB J196)

For Federal Reserve Bank Use Only
BHC RSSD ID
SUB RSSD ID
Public reporting burden for this information collection is estimated to average 7 hours per response, including time to gather and maintain data in the required form and to review instructions and complete the information collection. Comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing the burden,
may be sent 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 (7100-0300), Washington, DC 20503.
12/2016

For Federal Reserve Bank Use Only

Annual Report of Merchant Banking Investments Held for an
Extended Period—Continued

FR Y-12A
Page 2 of 2

BHC RSSD ID
SUB RSSD ID

Direct Holder's Name and Location
Legal Name (FHMB F189)

City / County (FHMB F190)
State / Province, Country (FHMB F191)

Zip / Postal Code (FHMB F192)

Covered Investment Section
2. Name and Location of Company Held:

1. Acquisition Date of Covered Investment:

Legal Name (FHMB F194)

(MM/DD/YYYY) (FHMB F193)

City / County (FHMB F195)

State / Province, Country (FHMB F196)

Zip / Postal Code (FHMB F197)

3. Primary Activity of Company Held:
Description of Activity (if no Activity Code applicable)
NAICS Activity Code
(FHMB F198)

(FHMB F199)

4. Type of Interest held by Financial Holding Company:
Common Stock
Preferred Stock
(FHMB F200)

(FHMB F276)

Warrants

General Partner
(FHMB F277)

Options

(FHMB F279)

(FHMB F280)

Limited Partner
(FHMB F278)

Convertible Debt
(FHMB F281)

Other
(FHMB F282)

If other, please describe:
(FHM8 F200)

5. Percentage of Ownership held by Financial Holding Company:
% Voting Equity
(FHMB F201)

% Nonvoting Equity
(FHMB F202)

6. Acquisition Cost of the Covered Investment: $

(in millions of U.S. dollars)
(FHMB F203)

7. Carrying Value of the Covered Investment: $

(in millions of U.S. dollars)
(FHMB F204)

8. Plan and Schedule for disposition of the Covered Investment:
(FHMB F205)

(FHM1 F205)

(FHM2 F205)

(FHM3 F205)

(FHM4 F205)
(FHM5 F205)

(FHM6 F205)

(FHM7 F205)

(FHM8 F205)

09/2012