Free Microsoft Word - SUPPLEMENTAL INSTRUCTIONS - FOR FDIC INSURED INSTITUTIONS1... - Indiana

SUPPLEMENTAL INFORMATION
State Form 1717 (R6/12-03) Part A

Department of Financial Institutions

FOR FDIC INSURED FINANCIAL INSTITUTIONS

Call Report Date

F.D.I.C. Certificate Number

Exact Corporate Title of Institution

City or Town

Line 1 and Line 2 should correspond to the FDIC's Call Report Information. Any revisions made to the FDIC's Call Report after submission of this Form would require the submission of an amended Supplemental Information Form.

CALL REPORT INFORMATION (Dollar Amounts in Thousands)
1. Total Assets (As shown on Call Report Schedule RC) 2. Total Trust Assets (As shown on Call Report Schedule RC-T) 3. Grand Total (Sum of Lines 1 & 2)

$ $ $

State of ___________________________________

County of __________________________________

}

SS:

I, _________________________________________________________________ of the above named institution, do solemnly swear that the statements and figures of the condition of the said institution are true and correct to the best of my knowledge and belief. Signature

Subscribed and sworn to before me this ____________ day of ______________________________________, 20_________ and certify that I am not an officer or director of the institution mentioned. Signature of Notary Public

Printed or typed name of Notary Public

County of Residence

Date commission expires

INSTRUCTIONS STATE CALL REPORT - SUPPLEMENTAL INFORMATION FORM STATE FORM 1717 (R7/12-03) Part A FOR FDIC INSURED FINANCIAL INSTITUTIONS
The purpose of the Supplemental Information Form is to provide the Department of Financial Institutions with information to be used in the supervision and examination of all financial institutions under the jurisdiction of the Department of Financial Institutions and as a basis for the calculation of the Department's annual supervisory assessment. The Supplemental Information Form and any attachments are to be filed on a semi-annual basis as of June 30 and December 31. Completed reports are to be delivered to the Department of Financial Institutions no later than 30 days following the date of the Call Report. Each financial institution must submit one copy to the Department and retain one copy of the report, including supporting documentation. The completion of this report is mandatory and is authorized pursuant to I.C. 28-115-1.

CALL REPORT INFORMATION 1. TOTAL BANKING ASSETS Report the total assets of the financial institution as reported on Schedule RC - Balance Sheet of the Call Report. TOTAL TRUST ASSETS Report the total market value of trust assets of the financial institution as reported on Schedule RC-T of the FDIC's Call Report. (For trust departments that are not required to report trust assets as of June 30 on Schedule RC-T, still provide the total market value of trust assets as of June 30.) GRAND TOTAL BANKING AND TRUST ASSETS Report the sum of lines 1 and 2.

2.

3.

An officer of the financial institution who has been authorized by the board of directors must certify the Supplemental Information Form. The title of the signing officer must be clearly indicated. The signature of the authorized officer must be notarized.