Form 7200/11 Declaration for IRA/KEOGH Deposit

OMB NUMBER: 3064-0143

EXPIRATION DATE: 08/31/2020

Federal Deposit Insurance Corporation

DECLARATION FOR IRA/KEOGH 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 IRA/KEOGH DEPOSIT

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

Financial Institution:      

Closing Date:      

Account Number:      

Customer Number:      

1. The deposit referenced above (the “Account”) was made in connection with the following type of retirement plan (Check all that apply):

An individual retirement account (IRA) described in section 408(a) of the Internal Revenue Code of 1986 (26 U.S.C. 408(a)).

An eligible deferred compensation plan described in section 457 of the Internal Revenue Code of 1986 (26 U.S.C. 457).

An individual account plan defined in section 3(34) of the Employee Retirement Income Security Act (ERISA) (29 U.S.C. 1002) or a plan described in section 401(d) of the Internal Revenue Code of 1986 (26 U.S.C. 401(d)) for which participants or beneficiaries have the right to direct the investment of assets held in individual accounts maintained on their behalf by the plan.

2. The trustee or administrator of the retirement plan(s) identified in item 1 is (are)       (Name of bank or other qualified person). Documentary evidence reflecting the authority of the trustee or administrator to serve in this capacity is attached hereto. (Attach IRS determination letter or other appropriate evidence.)

3. The undersigned is employed by the trustee or administrator in the following capacity:

     

    

4. The owner of the Account is       .

(Name of owner)

5. The relationship between the trustee or administrator and the deposit owner is governed by the agreement(s) or document(s) attached hereto. (Attach the IRA or Keogh or other agreement(s) in effect on the closing date. If the agreement is very lengthy, attach a sufficient number of pages to establish that the trustee or administrator entered into an agreement with the deposit owner.)

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:      

     
Name of Trustee or Administrator (Please print)		Signature of Trustee or Administrator

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. Any 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.