RESET
STATE OF TENNESSEE TREASURY DEPARTMENT
BANK COLLATERAL POOL BOARD
P.O. BOX 198785
NASHVILLE, TN 37219-8785
APPLICATION FOR ADMISSION
TO COLLATERAL POOL
Pursuant to Tennessee Code Annotated, Title 9, Chapter 4, Part 5, all information requested by this application form
must be submitted by the applicant before the application can be processed by the Treasurers office. Please return this
application package to the above address.
SCHEDULE A - GENERAL INFORMATION
1. FDIC Certificate #: __________________________
2. Date Submitted: ______________________________
3. ABA #: ___________________________________
4. State Bank #: ________________________________
5. Tax I.D. #: _________________________________________________________________________________
6. Legal Name of Depository: ___________________________________________________________________
7. Address of Principal Offices:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
8. Depository Charter Date: _____________________________________________________________________
9. Date Operation Commenced: __________________________________________________________________
10. Depository's Three Most Senior Officers:
Name
Title
E-Mail Address
______________________________
_________________________
_____________________________
______________________________
_________________________
_____________________________
______________________________
_________________________
_____________________________
11. Please attach a resume for each individual listed above listing experience and qualifications.
TR-0339
RDA-2393
SCHEDULE B - PUBLIC DEPOSITS HELD
Attention: Please provide a listing of all Public Depositors and their account numbers .
Average daily balance of public deposits held for prior month (in thousands):
Reporting for the:
Month ________________
Year _________________
1.
Average
Daily
Balance
2.
3.
Less
Deposit
Insurance
=
Insurance Adjusted
Average Daily
Balance
Demand Deposits
1a $__________
2a $ __________
=
3a
$ 0.00
__________
Time and Savings Deposits
1b $__________
2b $__________
=
3b
0.00
$__________
4. Total Deposits Held
=
$ 0.00
__________
5. Average monthly balance of public deposits for preceding 12 calendar months (in thousands):
Month-Year
Average Daily Balance for the Month Indicated
a. ________________________________________
_________________________________________
(as shown from line 4 of schedule B)
(prior month)
b. ________________________________________
_________________________________________
c. ________________________________________
_________________________________________
d. ________________________________________
_________________________________________
e. ________________________________________
_________________________________________
f. ________________________________________
_________________________________________
g. ________________________________________
_________________________________________
h. ________________________________________
_________________________________________
i. ________________________________________
_________________________________________
j. ________________________________________
_________________________________________
k. ________________________________________
_________________________________________
l. ________________________________________
_________________________________________
6. *Total $
_________________________________________
0.00
7. Calculate average monthly balance by dividing the total amount on number 6 by 12. The average monthly balance
0.00
of public deposits = $_____________________________.
Please refer to the instruction sheet prepared for Schedule B- Public Deposits Held.
TR-0339
RDA-2393
SCHEDULE C - TRUSTEE CUSTODIAN DECLARATIONS
Please list below all Trustee Custodians that the applicant will use to safeguard collateral pledged to the pool:
Trustee Custodian Name: __________________________
Address: _______________________________
Contact:
__________________________
_______________________________
Phone Number:
__________________________
_______________________________
Trustee Custodian Name: __________________________
Address: _______________________________
Contact:
__________________________
_______________________________
Phone Number:
__________________________
_______________________________
Trustee Custodian Name: __________________________
Address: _______________________________
Contact:
__________________________
_______________________________
Phone Number:
__________________________
_______________________________
All Trustee Custodians must be approved by the State Treasurers Office.
SCHEDULE D - DEBT RATING INFORMATION
List the debt rating from two (2) recognized rating agencies for your institution and your institution's holding company
(if applicable):
Date
Rating Agency
Institution Rating
Holding Company Rating
___________
_______________________
_____________
___________________
___________
_______________________
_____________
___________________
SCHEDULE E - FINANCIAL INFORMATION
Please list the following financial information:
Most recent Sheshunoff (presidents weight by peer group) rating: _________________________________
Date of quarter rated: ____________________
For the eight quarters immediately preceding the date of application, please complete the following schedule of financial
information to be taken from the Report of Condition to the FDIC (Call Report). Please use the table included in the instructions to determine the location of this information on your call report.
Please refer to the instruction sheet for each schedule.
TR-0339
RDA-2393
Call Report Type:
Item
q31
q32
q33
q34
______________________________________________________________________________________
(in thousands)
Total Equity Capital
(MM/YY)
_______________
(
)
_______________
(
)
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(
)
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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TR-0339
_______________
(
)
_______________
(
)
Other Real Estate Owned
(MM/YY)
_______________
(
)
_______________
(
)
Total Non-Accrual Loans
(MM/YY)
_______________
(
)
_______________
(
)
Loans Past Due 90 Days
(MM/YY)
_______________
(
)
_______________
(
)
Allowance for Loan Loss
(MM/YY)
_______________
(
)
_______________
(
)
Total Assets
(MM/YY)
_______________
(
)
_______________
(
)
Subordinated Notes & Debts
(MM/YY)
_______________
(
)
_______________
(
)
Limited Life Preferred Stock
(MM/YY)
_______________
(
)
_______________
(
)
_______________
(
)
_______________
(
)
RDA-2393
Net Income
(MM/YY)
_______________
(
)
_______________
(
)
_______________
(
)
_______________
(
)
_______________
(
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_______________
(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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(
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_______________
(
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_______________
(
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_______________
(
)
_______________
(
)
Regulatory (Tier 2) Capital
(MM/YY)
_______________
(
)
_______________
(
)
Regulatory (Tier 1) Capital
(MM/YY)
_______________
(
)
_______________
(
)
Total Loans
(MM/YY)
_______________
(
)
_______________
(
)
Average Assets
(MM/YY)
_______________
(
)
_______________
(
)
_______________
(
)
_______________
(
)
CERTIFICATION
Certification: hereby certify that the information contained in this application, including all attached reports, is true
and correct to the best of my knowledge.
Senior Bank Officer
Preparer
Signature: ______________________________________
Signature: ________________________________
Name:
______________________________________
Name:
________________________________
Title:
______________________________________
Title:
________________________________
Date:
______________________________________
Date:
________________________________
Telephone #: _______________________________
E-mail Address: ____________________________
Sworn to and subscribed before me:
Notary Public
Notary Seal
TR-0339
__________________
Date Commission Expires
__________________
RDA-2393
STATE OF TENNESSEE
BANK COLLATERAL POOL
INSTRUCTIONS FOR COMPLETING
THE COLLATERAL POOL APPLICATION FORM
Please use the following instructions when completing the application form to insure that the correct information is
being supplied. Should you have further questions concerning this application, please contact the Collateral Pool staff
at (615) 532-1168. Written inquiries may be faxed to (615) 741-0755.
Please note that the application form MUST be completed correctly to be processed. Incomplete applications will be
held until complete or returned if not completed. Thank you for your cooperation.
SCHEDULE A - GENERAL INFORMATION
1.
FDIC CERTIFICATE NUMBER is the Federal Deposit Insurance Corporations certificate number assigned
to your institution.
2.
DATE SUBMITTED is the date you return your application.
3.
ABA NUMBER is your American Bankers Association transit routing number.
4.
STATE BANK NUMBER is your three digit State Depository Number. If you are not a state depository,
signify with an N/A in this space.
5.
TAX I.D. NUMBER - Institution federal employment identification number.
6.
LEGAL NAME OF DEPOSITORY is the full legal name under which your institution is chartered.
7.
ADDRESS OF PRINCIPAL OFFICES is the primary business address for your bank and the address where
collateral pool correspondence will be directed.
8.
DEPOSITORY CHARTER DATE is the date of your charter.
9.
DATE OPERATIONS COMMENCED is the date your institution began conducting business.
10.
DEPOSITORYS THREE MOST SENIOR OFFICERS is a listing of the three officers having senior responsibility for your institution. Please give full names, full titles, and e-mail addresses.
11.
PLEASE ATTACH A RESUME is related to #10. Please include a resume or data sheet giving the experience
and qualifications of the three officers listed in #10.
SCHEDULE B - PUBLIC DEPOSITS HELD
Please list all public deposits being held as of the end of the last month PRIOR to the date your application was
submitted. This listing should include the name of the public depositor and the account number.
To calculate the total average daily balance of public deposits being held by your institution, use the following steps:
1. To calculate average daily balance, do the following steps:
a. Average Daily Demand Deposit - The total dollars by account of all public funds held on a daily basis in
demand deposit accounts during the calendar month immediately preceding the current month divided by the
number of calendar days in the month. Record this amount (in thousands) on line 1a.
b. Average Daily Time and Savings Deposit - Either the total dollars by account of all public funds held on a daily
basis in time and savings deposit accounts during the calendar month immediately preceding the current month
divided by the number of calendar days in the month; OR the higher of (1) the actual amount of public funds in
time deposit accounts on the last day of the calendar month immediately preceding the current month; or (2) the
sum of the amount of public funds in time deposit accounts on the last day of the two calendar months immediately preceding the current month divided by two. Record this amount (in thousands) on line 1b.
After calculating these balances, list the totals under the column entitled Average Daily Balance in the appropriate space.
2. Determine the amount of applicable Federal Deposit Insurance for these deposits using the guidelines established
by the FDIC. List these totals in the appropriate space in column 2.
3. Subtract the Deposit Insurance amount from the Average Daily Balance in column 1 in each category to obtain
the insurance adjusted Average Daily Balance. List the total for each category under the Adjusted Totals column.
4. Add the Adjusted Totals in column 3 to determine the Total Average Daily Balance of public deposits held for the
month reported.
5. To calculate the Average Monthly Balance of public deposits being held by your institution, use the following
steps:
Beginning with the month being reported on line a, list the month and year for each of the preceding 12 months in
the appropriate spaces in the month/year column (lines a-l). The Total Average Daily Balance of public deposits
held by the bank for each period being reported should be listed in the amount column. Total Average Daily
Balance of public deposits held should include ALL demand, time, and savings accounts being held for public
depositors, less the applicable federal deposit insurance. To determine these amounts, repeat steps 1-4 for each of
the previous months and insert in the spaces provided in #5 b-l.
6. After listing the totals in step #5, sum the amount column to determine the total of all Average Daily Balances of
public deposits held for the 12-month period listed. Write the total on line #6.
7. Divide the total of the monthly averages as determined in step #6 by 12 to calculate average monthly balance of
public deposits held. Record the amount on line #7.
SCHEDULE C - TRUSTEE CUSTODIAN DECLARATIONS
Please list all the Trustee Custodian Banks your institution will use to safe keep collateral securities pledged to the State
of Tennessee Collateral Pool. The full legal name of the institution, the primary person to contact, the phone number of
the contact, and the primary business address should be given in the proper space provided.
IMPORTANT NOTICE:
ALL TRUSTEE CUSTODIAN BANKS MUST BE APPROVED BY THE STATE
TREASURERS OFFICE.
SCHEDULE D - DEBT RATING INFORMATION
List in the spaces provided the debt ratings for your institution and your institutions holding company, where applicable. These ratings should be taken from two of the following recognized sources:
Moodys
Standard & Poors
SCHEDULE E - FINANCIAL INFORMATION
Sheshunoff Rating: Please give the most recent rating your institution has received from Sheshunoff Information
Services using the Presidents Weight by Peer Group rating. Where possible, this rating should be for the most recent
quarter reported immediately preceding the date your application was submitted. Indicate in the space provided the
quarter the rating was received.
For the eight quarters immediately preceding the date of application for admission to the pool, please list the requested
information in the appropriate spaces. The quarter and year of the information being reported should be noted across
the top of the table in the spaces provided. Care should be taken that the information given is under the proper quarter
and year. The (MM/YY) is to be used to insert the month in the MM and year in the YY spaces. For example, March
1994 would be (03/94). The most recent quarter should be listed first with the preceding seven (7) quarters listed in
chronological order.
The financial information supplied should be taken from your institutions Report of Condition (call report) as required
by the FDIC. A chart has been provided to aid in giving the correct location of each requested piece of information. The
chart gives the location of the information for each type of call report. Please verify the type of call report you use to
determine that you are using the correct location.
Certification Section: Pursuant to Rule 1700-4-1-.03(1)D of the Collateral Pool, the application MUST be executed
by both the president (or chief executive officer) and the person preparing the report. The signature, a printed or typed
name, official title, telephone number, and the date executed should be completed as required. The executed document
should then be notarized (the Notary seal must be affixed). An application will not be considered complete until this
section has been properly completed.
Description
Report #34
Amount (in thousands)
Location
Report #31
Report #32
Report #33
1. Total Equity $ ________________
Capital
Schedule
Line #
Page #
RI-A
14
RI-3
RI-A
13
RI-3
RI-A
13
RI-3
RI-A
13
RI-3
2. Limited Life $ ________________
Preferred Stock
Schedule
Line #
Page #
RC
22
RC-2
RC
22
RC-2
RC
22
RC-2
RC
22
RC-2
3. Subordinated$ ________________
Notes &
Debentures
Schedule
Line #
Page #
RC
19
RC-2
RC
19
RC-2
RC
19
RC-2
RC
19
RC-2
4. Total Assets $ ________________
Schedule
Line #
Page #
RC
12
RC-1
RC
12
RC-1
RC
12
RC-1
RC
12A
RC-1
5. Allowance $ ________________
for Loan Losses
Schedule
Line #
Page #
RC
4B
RC-1
RC
4B
RC-1
RC
4B
RC-1
RC
4B
RC-1
6. Loans Past $ ________________
Due 90 Days
Schedule
Line #
Page #
RC-N
9B
RC-18
RC-N
9B
RC-17
RC-N
6B
RC-16
RC-N
6B
RC-15
7. Total Non- $ ________________
Accrual Loans
Schedule
Line #
Page #
RC-N
9C
RC-18
RC-N
9C
RC-17
RC-N
6C
RC-16
RC-N
6C
RC-15
8. Other Real $ ________________
Estate Owned
Schedule
Line #
Page #
RC
7
RC-1
RC
7
RC-1
RC
7
RC-1
RC
7
RC-1
9. Net Income $ ________________
Schedule
Line #
Page #
RI
12
RI-3
RI
12
RI-2
RI
12
RI-2
RI
12
RI-2
10. Average
Assets
$ ________________
Schedule
Line #
Page #
RC-K
9
RC-13
RC-K
9
RC-12
RC-K
9
RC-11
RC-K
9
RC-10
11. Total Loans $ ________________
Schedule
Line #
Page #
RC
4D
RC-1
RC
4D
RC-1
RC
4D
RC-1
RC
4D
RC-1
12. Regulatory $ ________________
(Tier 1) Capital
Please calculate Tier 1 capital percentage for this quarter and give this percentage.
13. Regulatory $ ________________
(Tier 2) Capital
Please calculate Tier 2 capital percentage for this quarter and give this percentage.
RESOLUTION OF THE BOARD OF DIRECTORS
OF
_________________________________________________ (the “Depository”)
WHEREAS, the Board of Directors (the “Board”) of the Depository has determined that it is in the best
interest of the Depository to enter into that certain DEPOSITORY PLEDGE AND CONTINGENT
LIABILITY AGREEMENT between the Treasurer of the State of Tennessee and the Depository (the
“Agreement”), attached hereto as Addendum 1; and
WHEREAS, the Board of the Depository has delegated the authority to enter into the Agreement to
(please select the appropriate box):
the full Board of Directors or
the Loan Committee of the Board (the “Committee”); and
WHEREAS, the Board of the Depository has the authority to delegate such authority to enter into the
Agreement to the Committee, and such authority (such as, for example, the Depository’s bylaws, charter
of incorporation, articles of organization, articles of association, or operating agreement) is attached to
this Resolution as Addendum 2;
NOW, THEREFORE, the Board of the Depository or its Committee resolves as follows:
1.
That the Depository has heretofore entered into or intends to enter into the Agreement
and that a copy of the Agreement, together with a copy of this Resolution, has been or shall be
permanently maintained by the Depository in the Minutes of the Board of Directors or other permanent
corporate records; and
2.
That the Board of the Depository accepts the terms and conditions of the Agreement; and
3.
That the individuals who have executed or will execute the Agreement have the full legal
and corporate authority to bind the Depository to the terms of the Agreement; and
4.
That each member of the Board of the Depository or Committee has affixed his or her
signature to this Resolution, which may be executed in two or more counterparts, each of which shall be
deemed an original, but all of which together shall constitute one and the same instrument.
5.
That this Resolution shall be attached to and remain a permanent part of the Minutes of
the Board of Directors of the Depository, reflected in the minutes of the meeting held on _____________.
CERTIFIED, this _____ day of _____________________. 20___, as a true and correct Resolution of the
Board of the Depository, or of a Committee designated by the Board, by its Secretary.
______________________________________
Secretary of the Board or Committee
8986130_1.DOC
We, the members of the Board of Directors of ________________________________ (the “Depository”)
or the Members of the Depository’s _____________________ Committee certify that we have approved
the Agreement, attached hereto, and have affixed our signatures, certifying our approval of the
Resolution.
Print or type name
8986130_1.DOC
Signature
Date Signed
Addendum 1 – Depository Pledge and Contingent Liability Agreement
Attached
8986130_1.DOC
Addendum 2 – Copy of Corporate Authorization to Delegate Authority to Sign Agreement
to Committee of Board of Directors of Depository
Check the appropriate box and attach appropriate document(s) specifying Board’s
authority to delegate such authority to a Committee of the Board.
Charter of incorporation
Articles of association
Articles of organization
Operating agreement
Bylaws
Other:_______________________________________
8986130_1.DOC
or MEETING MINUTES
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