Form 7200/06 Declaration of Independent Activity

OMB NUMBER: 3064-0143

EXPIRATION DATE: 08/31/2020

Federal Deposit Insurance Corporation

DECLARATION OF INDEPENDENT ACTIVITY

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 OF INDEPENDENT ACTIVITY

INSTRUCTIONS: An executed copy of this Declaration of Independent Activity must be submitted before an insurance determination can be made on your Account. Please be sure to attach to this Declaration of Independent Activity all of the documentation requested in Item 6.

Financial Institution:      

Closing Date:      

Account Number:      

Customer Number:      

1. T he undersigned is       of      

(Title) (Name of Organization)

(the “Accountholder”) and is responsible for: (Describe Duties)

     

     

2. The Accountholder is engaged in the business of:

     

     

3. The source of funds for the above-listed Account was:

     

     

4. The major stockholders (if the Accountholder is a corporation) or partners (if the Accountholder is a partnership) of the Accountholder and their percentage ownership interest were the following on the closing date:

     

     

5. The officers and directors of the Accountholder on the closing date were the following:

     

     

6. Attached are (1) a copy of the certificate of good standing from the Secretary of State of incorporation dated no earlier than one year prior to the closing date or the certificate of partnership filed with the proper governmental authority; (2) a copy of the Articles of Incorporation or Partnership Agreement (whichever is applicable) for the Accountholder; (3a) the most recent separate income tax return filed with the Internal Revenue Service or (3b) the most recent financial statements.

7. Does the Accountholder have an ownership interest, directly or indirectly, in any other accounts at the closed institution?

Yes (Please provide account number)      

No

8. The undersigned, or any one of them has (have) been authorized to execute and deliver to the Federal Deposit Insurance Corporation (“FDIC”) information concerning the above-referenced Account at the closed institution and to take any and all other actions and to execute any and all other documents in connection with the payment of insurance on such Account and to subrogate to the FDIC the Accountholder’s rights in said Account to the extent such Account is insured. If not applicable, please check box.

Not Applicable

FDIC 7200/06 (5-17) Page 1

DECLARATION OF INDEPENDENT ACTIVITY (Continued)

9. The declaration is made to induce the FDIC to pay insurance covering the Account to the extent that the Account is covered by insurance.

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

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

Signature

     

Print Name

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 with the FDIC’s deposit insurance regulations. Public reporting burden for this collection of information is estimated to average .5 hours 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 of information unless it displays a currently valid OMB control number.

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