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

FR Y-12A
OMB Number 7100–0300
Avg. hrs. per response: 7.00
Expires December 2009

Board of Governors of the Federal Reserve System

Annual Report of
Merchant Banking Investments Held for an Extended Period—
FR Y-12A
Cover Page

Report Date

(MM/DD/YYYY)

Reporter's Name, Street, and Mailing Address
Legal Name
Street Address

Reporter's Mailing Address (if different from street address)

City/County

Mailing City

State/Province, Country

Zip/Postal Code

Mailing State/Province, Country

Zip/Postal Code

Contact's Name and Mailing Address for this Report

Name and Title

Contact's Mailing Address (if different from above)

Phone Number (Include area code and if applicable, the extension)

Mailing City

Fax Number (Include area code)

Mailing State/Province, Country

Zip/Postal Code

E-mail Address

Executive Officer
I,

,

Printed Name

,

Title

am an authorized officer of the company named above, and
hereby declare that this report is true and complete to the best of
my knowledge and belief.

Signature of Executive Officer

For Federal Reserve Bank Use Only
BHC RSSD ID
SUB RSSD ID

Date of Signature

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, Washington, D.C. 20551, and to the Office of Management and
Budget, Paperwork Reduction Project (7100–0300), Washington, D.C. 20503.
This report is required by law: Sections 4(k)(4)(H) and 5(c) of the Bank Holding Company Act
(BHC Act) (12 U.S.C. 1843(k)(4)(H) and 1844 (c)) and subpart J of the Board's Regualtion Y
(12 CFR 225.170 et seq.).

FR Y–12A
Page 1
For Federal Reserve Bank Use Only
BHC RSSD ID
SUB RSSD ID

Annual Report of Merchant Banking Investments Held
for an Extended Period (FR Y-12A)
Direct Holder's Name and Location
Legal Name
City/County

State/Province, Country

Zip/Postal Code

State/Province, Country

Zip/Postal Code

Covered Investment Section
1. Acquisition Date of Covered Investment:
(MM/DD/YYYY)

2. Name and Location of Company Held:
Legal Name
City/County

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

4. Type of Interest held by Financial Holding Company:
Common Stock
Preferred Stock
Warrants
Options

General Partner
Convertible Debt

Limited Partner
Other

If other, please describe:
5. Percentage of Ownership held by Financial Holding Company:
% Voting Equity
% Nonvoting Equity
6. Acquisition Cost of the Covered Investment: $

(in millions of U.S. dollars)

7. Carrying Value of the Covered Investment: $

(in millions of U.S. dollars)

8. Plan and Schedule for disposition of the Covered Investment:

06/06