5 DE Admin. Code 2206. Report of Delaware Assets

A. | Delaware Loans and Contracts | $

B. | Funds Deposited in Delaware | $

C. | Fixed Assets in Delaware | $

D. | Other Delaware Assets | $

(Describe: )

E. | TOTAL | $

5 Del.C. §2210(e)

Effective Date: April 11, 2014

Each licensee shall submit this report annually to the Office of the State Bank Commissioner. This report must be received no later than April 1 of each year and must contain information for the previous calendar year. The information reported should reflect DELAWARE assets only (including the value of any Delaware loans or contracts, any funds deposited in Delaware, and any fixed assets located in Delaware or any other assets allocated to the Delaware operations).

A completed, signed report may be scanned and submitted by e-mail to bco_reports@state.de.us no later than April 1.

Failure to submit this report when due will be a violation of this regulation. In addition, an examination may be scheduled and examination staff allocated without respect to the licensee’s amount of Delaware assets. This may result in additional examination costs.

1. Name of Licensee: __________________________________________________________

2. Address of Principal License: __________________________________________________

________________________________________________________________________

________________________________________________________________________

3. To whom should we mail the supervisory assessment invoice? Please provide name, title, complete mailing address, telephone number (include area code and extension numbers, if applicable) fax number and e-mail address:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

4

, telephone number (include area code and extension numbers, if applicable) fax number and e-mail address:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

4. DELAWARE assets as of December 31st of the immediately previous year:

I, the undersigned officer, hereby certify that this report is true and correct to the best of my knowledge and belief.

_____________ _________________________________ ________________________

Date Signature Title

_________________________________ ________________________

Printed Name Phone Number

1 DE Reg. 1414 (3/1/98)

17 DE Reg. 994 (04/01/14)