Quarterly Supplemental Reports

U.S. Department of the Treasury

Quarterly Supplemental Report for Banks ĂŶĚ^ĂǀŝŶŐƐƐƐŽĐŝĂƚŝŽŶƐParticipating in the Small Business Lending Fund
Select Quarter End Date
Call Report used to complete: ________________________

This Quarterly Supplemental Report supplements the Consolidated Reports of Condition and Income (Call Reports) filed by a bank or savings
association that has received capital from the U.S. Department of the Treasury (Treasury) through the Small Business Lending Fund. This Quarterly
Supplemental Report must be filed no more than 30 calendar days after the end of the calendar quarter, must be signed by the Chief Executive
Officer (CEO) and the Chief Financial Officer (CFO) of the reporting bank or savings association (or by the individuals performing equivalent
functions), and must be attested to by not fewer than two directors (trustees) for state nonmember banks and three directors for state member
banks, national banks, and savings associations.
We, the undersigned CEO and CFO (or equivalents) of the named bank
or savings association, attest that the Quarterly Supplemental Report
for this report date has been prepared in conformance with the
instructions issued by the Treasury and is true and correct to the best
of our knowledge and belief.

We, the undersigned directors (trustees), attest to the correctness of the
Quarterly Supplemental Report for this report date and declare that the
Quarterly Supplemental Report has been examined by us, and to the best
of our knowledge and belief, has been prepared in conformance with the
instructions issued by the Treasury and is true and correct.

_______________________________________________________
Signature of CEO (or Equivalent)

________________________________________________________
Signature of Director (Trustee)

Name
Date
_______________________________________________________
Signature of CFO (or Equivalent)

Name

Name

Name

Date

Select State

SBLF #

State
0

________________________________________________________
Signature of Director (Trustee)
Date

________________________________________________________
Signature of Director (Trustee)

Legal Title of Bank or Savings Association
City

Date

Zip

Name

Date

RSSD#

Submission of Report: Please refer to Instructions for Quarterly Supplemental Report document for submission information.
Freedom of Information Act
Please note that any information submitted by applicants may become
subject to public disclosure pursuant to the terms of the Freedom of
Information Act, 5 U.S.C. 552 (FOIA) and its exemptions. Nevertheless,
Treasury’s FOIA regulation, 31 C.F.R. 1.1 et seq., provides that, in
certain cases, businesses that submit information to Treasury shall
receive notice of a pending FOIA request for that information, as well
as an opportunity to object to the disclosure of any or all of that
information on the grounds that the information qualifies for
withholding under FOIA Exemption 4. See 31 C.F.R. 1.6.

To facilitate this business submitter notification process, Treasury
encourages applicants to designate any such information that they
believe, in good faith, is subject to FOIA Exemption 4. Such
designations will help Treasury to recognize instances in which
business submitter notification may be appropriate. Treasury reserves
sole discretion to determine whether such designated information
indeed qualifies for business submitter notification and, ultimately,
whether it qualifies for withholding pursuant to FOIA Exemption 4.
If you wish to identify any information on this form that you believe is
subject to FOIA Exemption 4, please identify that information and the
reasons for your request on attached pages.

Wire Information SBLF Institutions Should Use to Make Dividend or Interest Payments to Treasury:
Bank Name:
The Bank of New York Mellon
ABA (Routing) Number: 021000018
BNF Acct Name:
Income Collection
BNF Acct Number:
111566
REF:
Private Placements – SBJA
Security Name & CUSIP
Quarterly Supplemental Report for Banks and Savings Associations
Treasury Department Form: TD F 102.4 (05/03/2013) v6

1

OMB Number: 1505-0228

Quarterly Supplemental Report

for Banks and Savings Associations Participating in the Small Business Lending Fund
Table of Contents
Quarter-End Adjusted Baseline Calculation
Quarter-End Qualified Small Business Lending
Change in Qualified Small Business Lending Calculation
Every bank and savings association participating in the Small Business Lending Fund (SBLF) is required to submit a Quarterly
Supplemental Report no more than 30 calendar days after the quarter in which SBLF funding is received and in each of the following
quarters until all SBLF securities have been redeemed. Please refer to the Instructions for the Quarterly Supplemental Report for
Banks and Savings Associations Participating in the Small Business Lending Fund for guidance.
If you have general questions regarding this form, please contact the information line for the Small Business Lending Fund at
888-832-1147 (Monday-Friday, 9:00 AM-5:00 PM ET).

The Federal Government may not collect, and the public is not required to respond to, a collection of information that does not display a currently valid OMB Control Number. The control
number for this collection is 1505-0228.

Quarterly Supplemental Report for Banks and Savings Associations
Treasury Department Form: TD F 102.4 (05/03/2013) v6

2

OMB Number: 1505-0228

Quarterly Supplemental Report
for Banks and Savings Associations Participating in the Small Business Lending Fund

Quarter-End Adjusted Baseline Calculation
All banks and savings associations participating in the Small Business Lending Fund must complete this section. All figures are to be
reported in thousands of dollars. Amounts should reflect information on the Call Report with which the Quarterly Supplemental
Report is being filed. For ease of use, lines pre-populated with zeros are automatically calculated and will not accept manual entry.
Bil

1. Initial Small Business Lending Baseline (line 12 in the Initial Supplemental Report)

Mil

Thou

1

2. Prior quarter cumulative reported qualified small business lending increases resulting from an acquisition of, or merger with, another institution, and/or
purchases of such loans as were reported on line 12 of the prior quarter's submitted Quarterly Supplemental Report
3. Balance increases in commercial and industrial loans resulting from an acquisition of, or merger with, another institution, and/or purchases of such loans
4. Balance increases in loans secured by owner-occupied nonfarm, nonresidential properties resulting from an acquisition of, or merger with, another
institution, and/or purchases of such loans
5. Balance increases in loans to finance agricultural production and other loans to farmers resulting from an acquisition of, or merger with, another
institution, and/or purchases of such loans
6. Balance increases in loans secured by farmland resulting from an acquisition of, or merger with, another institution, and/or purchases of such loans
7. Subtotal (sum lines 3, 4, 5, and 6)

2
3
4
5
6
7

8. Dollar portion of any such loans or group of such loans to the same borrower and its affiliates with an original principal or commitment amount greater
than $10 million
9. Dollar portion of such loans to businesses with more than $50 million in revenues, unless included in line 8

000

0

000

0

000

000

0

000

000

8
9

10. Dollar portion of line 7 guaranteed by the U.S. government, unless included in lines 8 or 9

10

11. Dollar portion of line 7 where a third party has assumed an interest, unless included in lines 8, 9, or 10

11

12. Total cumulative reported qualified business lending increases resulting from an acquisition of, or merger with, another institution, and/or purchases of
such loans (line 12 equals line 2 plus line 7 minus lines 8, 9, 10, and 11)
13. Quarter-End Adjusted Small Business Lending Baseline (line 13 equals line 1 plus line 12)

12
13

Quarter-End Qualified Small Business Lending
All banks and savings associations participating in the Small Business Lending Fund must complete this section. All figures are to be
reported in thousands of dollars. Amounts should reflect information on the Call Report with which the Quarterly Supplemental
Report is being filed. For ease of use, lines pre-populated with zeros are automatically calculated and will not accept manual entry.
Quarter end
Bil
Mil

Dollar amounts in thousands
14. Balances of commercial and industrial loans (as reflected on Call Report Schedule RC-C, Part I, item 4)
15. Balances of loans secured by owner-occupied nonfarm, nonresidential properties (as reflected on Call Report Schedule RC-C, Part I, item 1.e.(1))
16. Balances of loans to finance agricultural production and other loans to farmers (as reflected on Call Report Schedule RC-C, Part I, item 3)
17. Balances of loans secured by farmland (as reflected on Call Report Schedule RC-C, Part I, item 1.b)
18. Subtotal (sum lines 14, 15, 16, and 17)

14
15
16
17
18

19. Dollar portion of any loans or group of loans to the same borrower and its affiliates with an original principal or commitment amount greater than $10
million
20. Dollar portion of such loans to businesses with more than $50 million in revenues, unless included in line 19
21. Dollar portion of line 18 guaranteed by the U.S. government, unless included in lines 19 or 20

0

000

000

0

000

000

19
20
21

22. Dollar portion of line 18 where a third party has assumed an interest, unless included in lines 19, 20, or 21
23. Total quarter-end qualified small business loans (line 23 equals line 18 minus lines 19, 20, 21, and 22)

22
23

Quarterly Supplemental Report for Banks and Savings Associations
Treasury Department Form: TD F 102.4 (05/03/2013) v6

Thou

3

OMB Number: 1505-0228

Quarterly Supplemental Report

for Banks and Savings Associations Participating in the Small Business Lending Fund
Net Charge-Off Adjustments

When completing this section, if net charge-offs are negative (i.e., recoveries exceed charge-offs), type a minus symbol (-) in the
“Neg (-)” column that corresponds to that line. Amounts should reflect the net charge-offs reported on the Call Report filed for the
same period as this Quarterly Supplemental Report. Charge-off amounts must be reported below as quarterly figures and not on a
year-to-date basis. For ease of use, lines pre-populated with zeros are automatically calculated and will not accept manual entry.
Net charge-offs
Neg (-) Mil
Thou

Dollar amounts in thousands
24. Cumulative net charge-offs before this quarter (line 34 from prior quarter’s report)

24

25. Net charge-offs on commercial and industrial loans

25

26. Net charge-offs on loans secured by owner-occupied nonfarm, nonresidential properties

26

27. Net charge-offs on loans to finance agricultural production and other loans to farmers

27

28. Net charge-offs on loans secured by farmland

28

29. Subtotal (sum lines 24, 25, 26, 27, and 28)

29

30. Dollar portion of net charge-offs on any such loans or group of such loans (from lines 25, 26, 27, and 28) to the same borrower and its affiliates with an
original principal or commitment amount greater than $10 million
31. Dollar portion of net charge-offs on such loans (from lines 25, 26, 27, and 28) to businesses with more than $50 million in revenues, unless included in
line 30
32. Dollar portion of net charge-offs on loans (from lines 25, 26, 27, and 28) guaranteed by the U.S. government, unless included in line 30 or 31

000

000

000

000

30
31
32

33. Dollar portion of net charge-offs on loans (from lines 25, 26, 27, and 28) where a third party has assumed an interest, unless included in line 30, 31, or 32

33

34. Total cumulative net charge-offs (line 34 equals line 29 minus lines 30, 31, 32, and 33)

34

35. Quarter-End Adjusted Qualified Small Business Lending (line 35 equals line 23 plus line 34)

35

Bil

Mil

0

Thou

000

000

Change in Qualified Small Business Lending Calculation

Complete this section to determine the percent increase in Qualified Small Business Lending. For ease of use, lines pre-populated with
zeros are automatically calculated and will not accept manual entry.
Bil
36. Dollar value of current balances with the Small Business Lending Fund
37. Dollar value of Quarter-End Adjusted Small Business Lending Baseline (line 13)
38. Dollar value of Quarter-End Adjusted Qualified Small Business Lending (line 35)
39. Dollar value of increase in Qualified Small Business Lending from baseline (line 39 equals line 38 minus line 37; if negative, enter 0 on line 39)

36
37
38
39

40. Percent increase in Qualified Small Business Lending (line 40 equals line 39 divided by line 37; must be calculated to two decimal points; if line 39
is 0, enter 0 on line 40)
40

Mil

0
0
0

000
000
000

Thou

Hund

000 000
000 000
000 000

0.00

%

Please note that the information provided for the Change in Qualified Small Business Lending Calculation and the name of the applicant
institution will be made available to the public when Treasury reports on bank and savings association participation in the Small Business
Lending Fund.

Quarterly Supplemental Report for Banks and Savings Associations
Treasury Department Form: TD F 102.4 (05/03/2013) v6

4

OMB Number: 1505-0228