U.S. Department of the Treasury

Quarterly Supplemental Report for Banks ĂŶĚ^ĂǀŝŶŐƐƐƐŽĐŝĂƚŝŽŶƐParticipating in the Small Business Lending Fund

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. 

Legal Title of Bank or Savings Association

City State Zip

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.

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

_______________________________________________________

Signature of CEO (or Equivalent)

Name Date

_______________________________________________________

Signature of CFO (or Equivalent) 

Name Date

SBLF # RSSD# 

________________________________________________________

Signature of Director (Trustee)

Name Date

________________________________________________________

Signature of Director (Trustee)

Name Date

________________________________________________________

Signature of Director (Trustee)

Name Date

Quarterly Supplemental Report for Banks and Savings Associations 1 

Treasury Department Form: TD F 102.4 (05/03/2013) OMB Number: 1505-0228
Quarterly Supplemental Report for Banks and Savings Associations 2

Treasury Department Form: TD F 102.4 (05/03/2013) v6 OMB Number: 1505-0228

QuarterlySupplemental 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 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.

Quarter-End Qualified Small Business Lending

Quarter end

Dollar amounts in thousands Bil Mil Thou

14. Balances of commercial and industrial loans (as reflected on Call Report Schedule RC-C, Part I, item 4) 14

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)) 15

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) 16

17. Balances of loans secured by farmland (as reflected on Call Report Schedule RC-C, Part I, item 1.b) 17

18. Subtotal (sum lines 14, 15, 16, and 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 19

20. Dollar portion of such loans to businesses with more than $50 million in revenues, unless included in line 19

20

21. Dollar portion of line 18 guaranteed by the U.S. government, unless included in lines 19 or 20 21

22. Dollar portion of line 18 where a third party has assumed an interest, unless included in lines 19, 20, or 21 22

23. Total quarter-end qualified small business loans (line 23 equals line 18 minus lines 19, 20, 21, and 22) 23

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

2 

3. Balance increases in commercial and industrial loans resulting from an acquisition of, or merger with, another institution, and/or purchases of such loans 3 

4 

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 5 

6. Balance increases in loans secured by farmland resulting from an acquisition of, or merger with, another institution, and/or purchases of such loans 6 

7. Subtotal (sum lines 3, 4, 5, and 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 8 

9. Dollar portion of such loans to businesses with more than $50 million in revenues, unless included in line 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)

 

12 

13. Quarter-End Adjusted Small Business Lending Baseline (line 13 equals line 1 plus line 12) 13 

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

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

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 Mil Thou

Quarterly Supplemental Report for Banks and Savings Associations 3 

Treasury Department Form: TD F 102.4 (05/03/2013) v6 OMB Number: 1505-0228
Quarterly Supplemental Report for Banks and Savings Associations 4

Treasury Department Form: TD F 102.4 (05/03/2013) v6 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 

Dollar amounts in thousands Neg (-) Mil Thou

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 30

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 31

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 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

Bil Mil Thou

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

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 Mil Thou Hund

36. Dollar value of current balances with the Small Business Lending Fund 36

37. Dollar value of Quarter-End Adjusted Small Business Lending Baseline (line 13) 37 000

38. Dollar value of Quarter-End Adjusted Qualified Small Business Lending (line 35) 38 000

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) 39 000

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 %

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.