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F E D E R A L RESERVE B A N K OF D A L L A S
DALLAS, TEXAS

75222

Circular No. 69-193
July 31 , 1969

FORM T -4
STATEMENT OF PURPOSE

To Brokers and Dealers
in the Eleventh Federal Reserve District:
In connection with the requirements of Regulation T,
Credit by Brokers and Dealers, as revised effective July 8 ,
1969, we are enclosing samples of Form T ^ - "Statement of Pur­
-t,
pose of an Extension of Credit by a Creditor," for use in
reproducing or obtaining from private printers your supply
of the form in exact duplicate.

Form T-^ is to be used for

all future credits which are not for the purpose of purchasing
or carrying or trading in securities.
If you have any questions concerning the form, we
shall be glad to answer them.

Yours very truly,
P. E. Coldwell
President
Enclosures ( +
')

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

F rR . Fotm T-4
6-69

B O A R D OF G O V E R N O R S OF T H E F E D E R A L R E S E R V E SYSTEM
STATEMENT OF PURPOSE OF AN EXTENSION OF CREDIT BY A CREDITOR
(FEDERAL RESERVE FORM T-4)
A FALSE OR DISHONEST STATEMENT BY THE CUSTOMER OR THE CREDITOR ON THIS FORM
MAY BE PUNISHABLE BY FINE OR IMPRISONMENT (U.S. CODE, TITLE 15, SECTION 78ff AND
TITLE 18, SECTION 1001)
Instructions:
(1) Please print or type (if space is inadequate attach separate sheet).
(2) In Part II “source of valuation" need be filled in only if such source is other than regularly published information
in journal of general circulation.
(3) This form need be obtained only if the purpose of the credit is other than to purchase, carry, or trade in securities
(see § 220.7(c) of Regulation T).

P A R T I (to be completed by customer (s))
(1) The purpose of this credit in the amount of $ .......... , which i unsecured or secured in
s
whole or in part by the collateral listed in Part I , is not to purchase or carry or trade in securities. It i
I
s
for the purpose of (describe in detail) .......... .............. ...........................

(2) This creditor, ................................................ has outstanding, or has
(N am e of cre d ito r)

agreed to extend, to the undersigned, the following other credits, which are not for the purpose of purchasing
or carrying or trading in securities, in addition to the credit described on this form (itemize and describe
briefly, including amounts and collateral i any). If none, so state ...........................
f

(3) Is any of the collateral listed in Part II(A) or (B) to be delivered, or has any such collateral
been delivered, from a bank, broker, dealer, or
If

person other than the undersigned? Yes □

yes, from whom?................ Against payment?

Yes □

No Q
No □

(4) Has any of the collateral listed in Part II (A) or (B) been owned less than six months?
Yes □ No □

If yes, identify a l such collateral so owned ....................................
l

The undersigned has (have) read this form and hereby certifies and affirms that to the best of my (our)
knowledge and belief the information contained on this form is true, accurate, and complete.
SIGNED ......... ..................................................................
(M an u al s ig n a tu re )

(D ate)

( P rin t or ty p e name)

SIGNED ............................................................................
(M anual s ig n a tu re )

( P rin t or type name)

(D ate)

P A R T I (to be completed by creditor)
I
(A) Collateral consisting of margin stock or margin securities consisting of debt securities con­
vertible into margin stock. The loan value of such stock under the current Supplement to Regulation T
is....... per cent;the loan value of such debt securities is........ per cent.
N o. o f sh ares
or
o th e r u n it

Item ize se p a ra te ly by issue

M a rk e t p ric e
p e r sh a re

Source o f
v a lu a tio n

T o tal m a rk e t
p ric e p e r
issue

(B) Collateral consisting of other securities, e.g., mutual fund shares, registered non-equity securities.
P a r value
o r o th e r
den o m in atio n

M a rk e t p ric e

S ource o f
va lu a tio n

T o tal m a rk e t
p ric e p e r
issue

C u rre n t
m a rk e t
value

Item ize s ep a ra te ly by issue

Source o f
v a lu a tio n

Good f a ith
loan value

(C) Other collateral.
Item ize

The undersigned, a duly authorized representative of the creditor has read this form, has accepted the
customer’s statement on Part I in good faith as defined below*, and hereby certifies and affirms that to the
best of his knowledge and belief all the information contained on this form is true, accurate, and complete.
Date ...........................................

•

SIGNED .............................................................................. ..................
(M an u al sig n a tu re )

( P r i n t o r ty p e n am e a n d title )

*
Regulation T requires that the customer’s statement on this form be accepted by the creditor acting in good faith.
Good faith requires that the creditor or his duly authorized representative (1) must be alert to the circumstances surrounding
the credit, and (2) if he has any information which would cause a prudent man not to accept the statement without inquiry,
has investigated and is satisfied that the statement is truthful. Among the facts which would require such investigation are
receipt of the statement through the mail or from a third party.

THIS F O R M M U S T B E R ETAINED B Y T H E CREDITOR F O R A T LEAST T H R E E Y E A R S A F T E R T H E
TERMINATION OF THIS CREDIT

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