Trust Examiner School - September 2023

Name of Instititution

Date of Information

(Column A) Gross Losses

(Column B) Gross Losses Non-Managed Accounts

(Column C) Recoveries

Memorandum -- Continued

Managed Accounts

Dollar Amounts in Thousands

Fiduciary settlement, surcharges, and other losses:

4.

c. Investment management agency accounts………………………….. b. Retirement related trust and agency accounts………………………. a. Personal trust and agency accounts………………………………… d. Other fiduciary accounts and related services……………………….. e. Total fiduciary settlements, surcharges, and other losses (sum of Memorandum items 4.a through 4.d) (sum of columns A and B minus column C must equal item 21)……………..

M.4.a. M.4.b. M.4.c. M.4.d.

M.4.e.

FIDUCIARY BALANCE SHEET

Dollar Amounts in Thousands

ASSETS

Net premsises and fixed assets including capitalized leases……………………………………………………………….. Accounts receivable………………………………………………………………………………………………………………… Loans and lease financing receivables (net)…………………………………………………………………………………… Other Real Estate Owned………………………………………………………………………………………………………….. Other Assets ……………………………………………………………………………………………………………………….. TOTAL ASSETS……………………………………………………………………………………………………………………… Notes Payable (12 mo. or more)………………………………………………………………………………………………..… Accrued Taxes……………………………………………………………………………………………………………………..… Accounts Payable…………………………………………………………………………………………………………………… Other liabilities…………………………………………………………………………………………………………………...….. Mortgages Payable…………………………………………………………………………………………………………………. TOTAL LIABILITIES………………………………………………………………………………………………………………….. Short-Term Notes Payable (12 mo. or less)……………………………………………………………………………………. D. Retained Earnings……………………………………………………………………………………………………………. A. Preferred Stock……………………………………………………………………………………………………………...…. B. Common Stock………………………………………………………………………………………………………..……….. C. Surplus…………………………………………………………………………………………………………………………. Cash and due from Banks………………………………………………………………………………………………………… Investment Securities………………………………………………………………………………………………………………. TOTAL EQUITY…………………………………………………………………………………………………………………...….. F. Dividends Paid YTD…………………………………………………………………………………………………………… E. Net fiduciary and related services income…………………………………………………………………………..……… TOTAL LIABILITIES & EQUITY…………………………………………………………………………………………..………….

1

1 . 2 . 3 . 4 . 5 . 6 . 7 . 8 .

2. 3. 4. 5. 6. 7. 8.

LIABILITIES 9.

9 .

10. 11. 12. 13. 14. 15. 17. 18. 19. 20. 21. 22. 23

10 . 11 . 12 . 13 . 14 . 15 . 16 . 17 . 18 . 19. 20. 21. 22. 23.

EQUITY CAPITAL 16.

I, the undersigned officer, do hereby declare that this Fiduciary Report of Condition and Income has been prepared in conformance with offical instructions and is true and correct.

Name and Title of Officer

Email Address

Telephone: Area code/phone number/extension

Fax: Area code/phone number

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