Form FR T-4 FR T-4 Statement of Purpose for an Extension of Credit by a Cre

FR T-4
OMB No. 7100-0019
Approval expires January 31, 2014

BOARD OF GOVERNORS OF THE FEDERAL RESERVE SYSTEM

Statement of Purpose for an Extension of Credit by a Creditor
(Federal Reserve Form T-4)
Name of Creditor

This form is required by law (15 U.S.C. 78g and 78w; 12 CFR 220).
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.
Public reporting burden for this collection of information is estimated to average
10 minutes per response, including the time to gather and maintain data in the

required form and to review instructions and complete the information collection.
Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden to Secretary, Board of
Governors of the Federal Reserve System, 20th and C Streets, N.W., Washington,
DC 20551; and to the Office of Management and Budget, Paperwork Reduction
Project (7100-0019), Washington, DC 20503.

Instructions
1. This form must be completed only if the purpose of the credit being extended is not to purchase, carry, or trade in securities and
the credit is in excess of that otherwise permitted under Regulation T. (See § 220.6(e)(2)).
2. Please print or type (if space is inadequate, attach separate sheet).

Part I To be completed by customer(s)
1. What is the amount of the credit being extended?
2. The borrower acknowledges that no part of this credit will be used to purchase, carry, or trade in securities. The purpose of the
credit is described in detail as follows:

3. Are any of the securities listed in Part II to be delivered, or have any such securities been delivered from a bank, broker, dealer, or
other person on a “delivery against payment” basis?
Yes
No

I (We) have read this form and certify that to the best of my (our) knowledge and belief the information given is true, accurate, and
complete.
Signed:

Borrower’s signature

Print or type name

Signed:

Date

Borrower’s signature

Date

Print or type name

This form should not be signed if blank.
A borrower who falsely certifies the purpose of a credit on this form or otherwise willfully or intentionally evades
the provisions of Regualtion T will also violate Federal Reserve Regulation X, “Borrowers of Securities Credit.”

FR T-4
Page 2 of 2

Part II To be completed by creditor
The following is a listing of collateral, if any, securing this credit.
1. Collateral consisting of securities with loan value under Regulation T (refer to the Supplement to Regulation T).
No. of shares
or other unit

Market price

Itemize separately by issue

Date and source
Total market
of valuation
value per issue
(See note below)

2. Collateral consisting of securities having no loan value under Regulation T.
No. of shares
or other unit

Itemize separately by issue

Market price

Date and source
Total market
of valuation
(See note below) value per issue

3. Other collateral.
Current market
value

Itemize

Date and source
of valuation
(See note below)

Good faith
loan value

Note: Creditor need not complete “Date and source of valuation” if the market value was obtained from regularly published or disseminatied information in either a journal of
general circulation or automated quotation system.

I am a duly authorized representative of the creditor. I have read this form and any attachments, and have accepted the customer’s
statement in Part I in good faith as defined below,* and I certify that to the best of my knowledge and belief, all the information given
is true, accurate, and complete.
Signed:

Date

Authorized representative’s signature

Title

Print or type name

* To accept the customer’s statement in good faith, the duly authorized representative of the creditor must be alert to the circumstances surrounding the credit and, if in
possession of any information that would cause a prudent person not to accept the statement without inquiry, must have investigated and be satisfied that the statement is
truthful. Among the facts which would require such investigation are receipt of the statement through the mail or from a third party.

This form must be retained by the lender for three years after the credit is extinguished.