7200-09 Declaration for Testamentary Deposit (Multiple Grantors)

OMB NUMBER: 3064-0143

EXPIRATION DATE: 07/31/2008

Federal Deposit Insurance Corporation

DECLARATION FOR TESTAMENTARY DEPOSIT

(MULTIPLE GRANTORS)

INSTRUCTIONS: Please type or print all information legibly, date, and sign.

F inancial Institution:      

Closing Date:      

Account Number:      

Group Number:      

1. We, the undersigned, declare that we are the Grantors of the above account (the “Account”) and constitute all of the persons

who own all of the funds in the Account according to the following percentages:

	NAME OF GRANTORS		PERCENTAGE OF FUNDS CONTRIBUTED TO THIS ACCOUNT
(A)	     		     
(B)	     		     
			Note: Percentages must equal 100%

2. We further declare that our intent in establishing the Account was to provide that the funds in the Account, upon

our deaths, would be owned by the beneficiaries identified below.

3. The beneficiaries of the account and the relationship of each of them to each of the undersigned are as follows:

NAME OF BENEFICIARY		RELATIONSHIP TO (A)		RELATIONSHIP TO (B)
     		     		     
     		     		     
     		     		     
     		     		     
     		     		     

4. Each of the above-named beneficiaries is presently living. If any beneficiary is deceased, please indicate name and date of death:

NAME		DATE OF DEATH
     		     
     		     
     		     

5. If the funds in this Account were placed by you as grantors under a written trust agreement, other than the account signature card, attach a true, exact and complete copy of the trust agreement as in effect on the closing date. Note: Be sure to attach this Declaration to the copy of the Trust.

6. This declaration is made to induce the Federal Deposit Insurance Corporation to pay insurance covering the Account to the extent that the Account is covered by insurance.

7. This declaration, under penalty of perjury, is executed pursuant to 28 U.S.C. § 1746.

I declare under penalty of perjury that the foregoing is true and correct. Executed on:       .

Signature of Grantor		Signature of Grantor

THE PENALTY FOR KNOWINGLY MAKING OR INVITING RELIANCE ON ANY FALSE, FORGED OR COUNTERFEIT STATEMENT, DOCUMENT OR THING FOR THE PURPOSE OF INFLUENCING IN ANY WAY THE ACTION OF THE FEDERAL DEPOSIT INSURANCE CORPORATION IS A FINE OF NOT MORE THAN $1,000,000 OR IMPRISONMENT FOR NOT MORE THAN THIRTY YEARS OR BOTH (18 U.S.C. § 1007).

P APERWORK REDUCTION ACT NOTICE

The information collected is required for the determination of insured deposits when a financial institution closes in accordance to Deposit Insurance Rules and Regulations. Public reporting burden for this collection of information is estimated to average 1/2 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17^th Street, N.W., Washington, D.C. 20429, and the Office of Management and Budget, Paperwork Reduction Project (3064-0143), Washington, D.C. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

FDIC 7200/09 (10-05)