Form 7200/05 Declaration for Revocable Trust

PRIVACY ACT STATEMENT

The Federal Deposit Insurance Act (12 U.S.C. §§ 1819, 1821, and 1822) and 12 C.F.R. Part 330 authorize the collection of this information.  The purpose for collecting this information is to support the determination of deposit insurance coverage and/or the payment of deposit insurance on deposits of the closed financial institution.  Furnishing this information is voluntary but failure to provide the requested information in whole or in part may delay or prevent the determination of deposit insurance coverage and/or the payment of deposit insurance on deposits of the closed financial institution.  The information provided by individuals is protected by the Privacy Act, 5 U.S.C. 552a.  The information may be furnished to third parties, including law enforcement authorities, as authorized by law, or used according to any of the other routine uses described in the FDIC Insured Financial Institution Liquidation Records (FDIC-30-64-0013) System of Records.  A complete copy of this System of Records is available at www.fdic.gov/about/privacy/index.html.   If you have questions or concerns about the collection or use of the information, you may contact the FDIC’s Chief Privacy Officer at Privacy@fdic.gov.

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Federal Deposit Insurance Corporation

DECLARATION FOR REVOCABLE LIVING TRUST

INSTRUCTIONS: Please type or print all information legibly, date, and sign. See page 2 for the Paperwork Reduction Act Notice.

F inancial Institution:      

Closing Date:      

Account Number:      

C ustomer Number:      

1. The undersigned is (are) trustee(s) of the attached Trust (the “Trust”) for which the above-referenced account(s) (the “Account(s)”) was/were established. The documents creating said Trust are attached to this declaration.

2. The names of all of the trustee(s) of said Trust on the closing date were:

     

     

3. The settlor(s)/grantor(s) of said Trust and their respective contributions are:

NAME			PERCENTAGE OF FUNDS CONTRIBUTED TO THIS ACCOUNT
(A)	     		     
(B)	     		     

Note: Percentages must equal 100%

NOTE: The information above (percentage of funds contributed by each co-owner) may or may not be used by the FDIC in calculating the insurance coverage of the Account. In the case of qualifying joint accounts held as tenants in common, the interests of the co-owners are deemed equal unless otherwise stated in the depository institution’s deposit account records.

12 C.F.R. § 330.10(f).

If any grantor is deceased, complete the following:

Name		Date of Death
     		     
     		     

4. List the beneficiaries of the Trust:

	BENEFICIARY		BENEFICIARY TYPE (Individual/Charity/ Non-Profit)		IF INDIVIDUAL, IS THE PERSON LIVING? (Check applicable box)			IF CHARITY OR NON-PROFIT, IS IT RECOGNIZED BY THE IRS? (Check applicable box)
					Yes	No		Yes	No
	     		     
	     		     
	     		     
	     		     
	     		     
	     		     
	     		     
	     		     
	     		     

FDIC 7200/05 (5-17) Page 1

DECLARATION FOR REVOCABLE LIVING TRUST (Continued)

5. The undersigned, or any one of them [STRIKE IF NOT APPLICABLE], has (have) the authority under the Trust to execute, on behalf of the Trust, this Declaration and all other documents which the Federal Deposit Insurance Corporation may require to be executed in connection with the payment of insurance on the Account(s) and to bind the Trust by his or her action.

6. This declaration is made to induce the Federal Deposit Insurance Corporation to pay insurance covering the Account(s), to the extent the Account(s) is (are) 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:      .

     
Trustee Name (Please Print)		Trustee Signature

     
Trustee Name (Please Print)		Trustee Signature

Note: Please be sure to attach the Trust documents to this Declaration.

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 close in accordance with the FDIC’s deposit insurance regulations. Public reporting burden for this collection of information is estimated to average 30 minutes 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 Paperwork 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 unless it displays a currently valid OMB control number.

FDIC 7200/05 (5-17) Page 2