7200.12 Declaration for Defined Benefit Plan

OMB NUMBER: 3064-0143

EXPIRATION DATE: 07/31/2008

Federal Deposit Insurance Corporation

DECLARATION FOR DEFINED BENEFIT PLAN

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

F inancial Institution:      

Closing Date:      

A ccount Number:      

G roup Number:      

1 . The undersigned is the actuary for the       Plan (the “Plan”) for which account number       was established at       .

2. The undersigned is presently enrolled by the Joint Board for the Enrollment of Actuaries.

3. There were       participants in the Plan on the closing date.

4. If the above account(s) had an aggregate balance of LESS than $102,000 on the closing date, did the present value of any one participant’s accrued benefit (including rollover, other voluntary participant contributions and any other amounts held for the benefit of the participant) exceed 95% of the total Plan assets on the closing date?

Yes No

5 . The largest percentage interest which any participant had in the Plan on the closing date was      %. The name of such participant is       . The percentage interest in the Plan was determined by dividing the present value of each participant’s accrued benefit (including rollover, other voluntary participant contributions and any other amounts held for the benefit of the participant) by the total Plan assets.

6. The present value of all participants’ accrued benefits in the Plan (including rollover and other participant contributions) was at least       % and no greater than       % of total Plan assets on the closing date.

7. The present value of each participant’s accrued benefit was determined for the purpose of this Declaration by using the interest rate and mortality assumptions stated in the Plan.

8. The above account is an investment of (Please check one):

General Plan assets which are made on behalf of all participants in the Plan

Self-directed funds or segregated funds

9. Have any participants made voluntary participant contributions, rollover contributions or trustee-to-trustee transfers to the Plan (excluding a trustee-to-trustee transfer from a plan with the same sponsor as the Plan discussed above)?

Yes No

10. Attached is a copy of the most recent actuarial report for the Plan (only required if the account(s) for the Plan exceeds $102,000

or if there are any other accounts for an employee benefit plan with the same sponsor).

11. 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.

12. 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       .

Actuary Signature

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).

PAPERWORK 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 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, Paper Reduction Act Project, 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 7200/12 (10-05)