Independent Credit Card Bank Receivables Form

Washington, DC 20219

Independent Credit Card Bank Receivables Form
Please complete sections A through C to provide reporting requirements for Independent Credit Card Banks. This
information is due 30 days prior to each semiannual payment date. Please fax completed forms to OCC Bank Assessments at
(571) 465-4324. For specific questions concerning assessments, please contact us at (202) 649-7946.

A. BANK INFORMATION
Charter Number:

Bank Name:

Bank City, State:

B. RECEIVABLES ATTRIBUTABLE TO CREDIT CARD ACCOUNTS
Receivables attributable* is not separately reported in the quarterly call report. To calculate the independent credit card assessment, it is
necessary for you to provide the amount of total off balance sheet receivables attributable ($ in millions) to credit card accounts owned by
your institution as of the most recent December 31 or June 30 call report date. If there are no receivables that meet this requirement,
please indicate NONE.
Amount ($ in millions):

*Receivables attributable is the total amount of outstanding balances due on credit card accounts owned by an independent credit card
bank (the receivables attributable to those accounts) on the last day of the call report date, minus receivables retained on the bank's
balance sheet as of that day.

C. SIGNATURE
Signature:

Date:

Printed Name:

Phone:

Last Updated: 04/13