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FEDERAL RESERVE BANK
OF DALLAS

Dallas, Texas, December 19, 1941

NOTICE REGARDING THE “STATEMENT OF BORROWER”
PRESCRIBED FOR USE IN CONNECTION WITH REGULATION W

To All Banking Institutions, and Others Concerned,
in the Eleventh Federal Reserve District:
Regulation W, relating to consumer credit, which was issued by the Board of Gov­
ernors of the Federal Reserve System pursuant to Executive Order No. 8843 of the Pres­
ident of the United States, provides that, on and after January 1, 1942, no Registrant
shall make any extension of instalment loan credit (with certain exceptions) unless, at or
before the execution of the loan contract, he obtains and accepts in good faith a signed
Statement of the Borrower as to the purposes of the loan in the form prescribed by the
Board.
A specimen copy of the form which the Board has prescribed for use in this connection
is enclosed. The forms will not be supplied by the Board or by this Bank but should be
printed or otherwise reproduced by the Registrant or obtained by him from stationery or
supply houses. Your attention is called to the fact that the form should be reproduced only
in accordance with the instructions at the top of the specimen form. Your attention is
also called to the fact that Registrants are instructed to keep all such statements on file.
Any inquiry relating to this form should be addressed to the Federal Reserve Bank
of Dallas or to one of its branches at Houston, San Antonio and El Paso.
Although the “ Statement of Borrower” is prescribed for use only in connection with
the extension of instalment loan credit, this circular and form are being sent to dealers and
other registrants for their information.

Yours very truly,
R. R. GILBERT
President

This publication was digitized and made available by the Federal Reserve Bank of Dallas' Historical Library (FedHistory@dal.frb.org)

SPECIMEN

FORM

Form F. R. 564.

FOR IN FORM ATI 9N OF REGISTRANT OR PRINTER ON LY— N O T T O BE PRINTED AS PART OF FORM:

In reproducing this form,
the Registrant or printer shall follow exactly the wording and arrangement o f the front and back of the form, hut may vary the spacing as desired.
Additions to the form, such as an acknowledgment by the borrower that he has received a copy, are permitted provided they do not call for the obtaining
o f any additional information from the borrower.
Since the form may be changed from time to time, it is suggested that Registrants do not stock large supplies o f the form.

STATEM EN T OF BORROWER
Prescribed by the Board of Governors of the Federal Reserve System under its Regulation W , issued pursuant to
Executive Order N o . 8843 of the President of the United States.

TO BE FILLED IN BY REGISTRANT
(Name of Registrant)

--------------------(D ate of Loan)

$----------------------(Amount of Loan)

(Answer “ Yes” or “ No” )

1.

Is any of the money from this loan to be used to buy a Listed Article?
(See statement on back of this sheet)

2.

Is any part of this loan to be secured by any Listed Article which you have
bought within the last 45 days or which you intend to buy?

3.

Is any of the money from this loan to be used to pay all or part of any

(A nsw er)

(A nsw er)

instalment debt?
(A nsw er)

4.

Is any of the money from this loan to be used as a down payment on the
purchase of a Listed Article?
(A nsw er)

In determining whether any article involved in this loan is a Listed Article, I have been guided by information furnished
by the lender.

I certify that, to the best of my knowledge, the information given by me on this sheet is true and

complete.

(Borrower’ s Signature)

(D a te)

5. IF EITHER Q UESTION 1 OR 2 HAS BEEN ANSWERED "YES”, the following information must be obtained
from' borrower:
Listed Article Bought or To Be Bought
or Used as Security

------------------------------------------------

Purchase
Price

$____________

H ave you borrowed any money elsewhere, or do you intend
specified above?

___________________________

Date Purchased
W before loan)

_____________
to

borrow any,

I f "Y e s ” , how much?

to be

Trade-in
Allowance

Amount
To Be Borrowed

$-------------------

$--------------------

used in buying any of the Listed Articles

$--------------------------------

(Answ er “ Yes” or “ No” )

6. IF QUESTION 3 HAS BEEN ANSWERED "YES”, the following information must be obtained from borrower:
Name of Person Holding Debt

N O TICE T O LENDER.— The

Total
Unpaid Balance

Instalment Terms

Amount
To Be Paid Off

lender, acting in good faith, may rely upon the above statements of the borrower.

H ow ­

ever, this form does not provide all of the information that it may be necessary for the lender to have if he intends to
avail himself of certain provisions of Regulation W .

In any case as to which the lender must obtain additional infor­

mation in order to be protected in making the particular loan under consideration, the facts themselves will govern.
This, however, does not affect the right of the lender to rely upon statements of fact obtained from the borrower pur­
suant to applicable provisions of the Regulation.

THE REGISTRANT RECEIVING THIS STATEMENT MUST KEEP IT ON FILE

LISTED ARTICLES
The instalment purchase of classes of consumers’ durable goods using materials, labor, and equipment needed for national
defense is regulated under the President’s Executive Order N o . 8843.

Regulation W

covers the extension of credit to buy

these articles, whether bought directly on instalment payments or with money borrowed on an instalment basis.
lowing are the classes of "Listed Articles” based upon the Supplement of Regulation W
articles may be added to or taken from the list at any time.

I N D E T E R M I N I N G W H E T H E R A N A R T IC L E I N ­

V O L V E D I N A L O A N IS A "L I S T E D A R T IC L E ” A B O R R O W E R M A Y
F U R N IS H E D B Y T H E LE N D E R , A N D
CH AN G ES IN

The fol­

in effect December 1, 1941, but

BE G U I D E D

B Y IN F O R M A T IO N

R E G IS T R A N T S M U S T KEEP T H E M S E L V E S IN F O R M E D A S T O

T H E S E "L I S T E D A R T IC L E S ” .

PASSENGER AUTOMOBILES
AIRCRAFT
MOTOR BOATS A N D BOAT MOTORS
MOTORCYCLES A N D MOTOR BICYCLES
REFRIGERATORS A N D ICEBOXES
W ASH IN G OR IRONING MACHINES
VA CU U M CLEANERS
COOKING STOVES
HEATING STOVES A N D HEATERS
ELECTRIC DISHWASHERS
AIR CONDITIONING EQUIPMENT
SEWING MACHINES

RADIOS A N D PHONOGRAPHS
M ETAL MUSICAL INSTRUMENTS
FURNACES, OIL OR GAS BURNERS, A N D STOKERS
W ATER HEATERS A N D PUMPS
PLUMBING A N D SANITARY FIXTURES
A T T IC VENTILATING FANS
NEW HOUSEHOLD FURNITURE, BED SPRINGS A N D
MATTRESSES
PIANOS AN D ELECTRIC ORGANS
MATERIALS A N D SERVICES USED IN CONNECTION
W IT H REPAIRS, ALTERATIONS, OR IMPROVEMENTS
OF BUILDINGS

WARNING
Regulation W provides that no borrower shall willfully make any material misstatement or omission in his
Statement. The law under which the President’s Executive Order was issued reads in part: "W hoever willfully
violates any of the provisions of this subdivision or of any license, order, rule or regulation issued thereunder, shall,
upon conviction, be fined not more than $10,000, or, if a natural person, may be imprisoned for not more than ten
years, or both; and any officer, director, or agent of any corporation who knowingly participates in such violation
may be punished by a like fine, imprisonment, or both.”


Federal Reserve Bank of St. Louis, One Federal Reserve Bank Plaza, St. Louis, MO 63102