Form 7200/08 Declaration for Joint Ownership Deposit

OMB NUMBER: 3064-0143

EXPIRATION DATE: 08/31/2020

Federal Deposit Insurance Corporation

DECLARATION FOR JOINT OWNERSHIP DEPOSIT

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 JOINT OWNERSHIP DEPOSIT

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

Financial Institution:      

Closing Date:      

Account Number:      

Customer Number:      

1. We,      

declare that we are the owners of all of the funds in the

above account (the “Account”).

2. We further declare that we own these funds jointly (as joint tenants with right of survivorship, as tenants in common, or as tenants by the entirety).

3. We further declare we own the funds according to the following percentages:

Name		Percentage of Funds Contributed
     		     
     		     
     		     

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. § 330.9(e).

4. If any owner is deceased, complete the following.

Name		Date of Death
     		     
     		     
     		     

5. Were the funds in this Account placed by (i) a trustee under a written trust agreement other than the account signature card, (ii) an agent, or (iii) attorney-in-fact? Yes No

If yes, identify the trustee, agent, or attorney-in-fact:      

Please attach a true, exact and complete copy of the trust agreement, agency agreement or power of attorney as in effect on the closing date.

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 Co-Owner		Signature of Co-Owner		Signature of Co-Owner
\ 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.