5 Del. Admin. Code § 2904-1.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 2904-1.0

This report shall be completed annually by all institutions licensed under Chapters 21, 22, and 29, Title 5 of the Delaware Code. This report must be received by the Office of the State Bank Commissioner no later than April 1st of each year. The figure reported should reflect DELAWARE assets only (including the value of any Delaware loans or contracts in your portfolio, any funds deposited in Delaware, and any fixed assets located in Delaware or any other assets allocated to the Delaware operations)

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) and fax numbers:

________________________________________________________________________

_______________________________________________________________________

4. Total DELAWARE assets as of December31st 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 (03/01/98)

5 Del. Admin. Code § 2904-1.0