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, 2023
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 (i.e., top-tier financial holding company),
Name, Street, and Mailing Address

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

Legal Name of Reporter (RSSD 9017)

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)

E-mail Address (FHMB 4086)

State / Province, Country (FHMB F209)

Zip / Postal Code (FHMB 9189)

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)

12/2020

FR Y-12A
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Annual Report of Merchant Banking Investments Held for an
Extended Period—Continued
Direct Holder's Name and Location
RSSD ID (FHMB F507)1

Legal Name (FHMB F189)

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

Zip / Postal Code (FHMB F192)

Covered Investment Section
1.

2. Name and Location of Company Held:

Acquisition Date of Covered Investment:

Legal Name (FHMB F194)

(MM/DD/YYYY) (FHMB F193)

1a. Holding Period Expiration Date of Covered Investment:

City / County (FHMB F195)

(MM/DD/YYYY) (FHMB JF96)

3.

Zip / Postal Code (FHMB F197)

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

4.

State / Province, Country (FHMB F196)

(FHMB F199)

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 thousands of U.S. dollars)
(FHMB F203)

7.

Carrying Value of the Covered Investment: $

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

8.

Past Efforts and Future Plan, Including Timing, to Achieve Disposition of Covered Investment Within the Holding Period:
(FHMB F205)

*1. Please contact you supervising Reserve Bank if the direct holder does not currently have an RSSD ID.

12/2019