Comptroller's Licensing Manual

OMB no. 1557-0014

Expiration date: See www.occ.gov

Voluntary Liquidation

Final Report

Applicant

____________________________________________________________________

Name Charter no.

____________________________________________________________________

Current street address

____________________________________________________________________

City County State Zip code

Parent Company Identifying Information (if applicable)

____________________________________________________________________

Name

____________________________________________________________________

Street

____________________________________________________________________

City State Zip code

Contact Person

____________________________________________________________________

Name Title

____________________________________________________________________

Employer

____________________________________________________________________

Street

____________________________________________________________________

City State Zip code

____________________________________________________________________

Telephone no. Fax no. E-mail address

Voluntary Liquidation—Final Report Filed Pursuant to 12 CFR 5.48(e)(6)

Liquidation start date:

Effective date of liquidation:

Since the (original/last reported) appointment of the liquidating agent/committee, the shareholders have made the following changes:

Name and address of appointed agent: Appointed to succeed: Date:

Aggregate book value of assets originally received by agent/committee: $

Cash originally received by agent/committee: $

TOTAL: $

Present book value of remaining unliquidated assets: $

Cash on hand: $

TOTAL: $

The following distribution to shareholders, if any, has been declared:

Date declared:

Distribution amount:

Percent of distribution:

If the bank had a trust department, show the disposition since liquidation.

Number of fiduciary accounts as of the liquidation start date:

Number of fiduciary accounts closed, transferred, or otherwise disposed of since the liquidation start date:

(Bank name) certifies that (as applicable):

• Any and all creditor claims, including all additional claims asserted during the period of advertisement for claims, have been fully paid or assumed by an operating bank.

• All remaining assets have been distributed.

• Any outstanding balances in liquidation accounts have been distributed.

• The board of directors and shareholders voted to liquidate the bank.

• Reports of examination (OCC/OTS) are enclosed or have been destroyed.

• Charter certificate/document, branch authorization, trust authority approval letter, is enclosed or is lost.

Enclosed (as applicable):

• Charter certificate/document

• Branch authorizations

• Trust authorizations

• Reports of examination

The following arrangements have been made for the retention of key bank records and the OCC’s access to those records:

____________________________________________________________________

(Liquidating agent) (Correspondent for committee)

____________________________________________________________________

(Committee member)

____________________________________________________________________

(Committee member)

____________________________________________________________________

(Committee member)

_________________________________

Date signed

(If there is a liquidating committee, every member should sign.)

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