7200/10 Declaration for Defined Contribution Plan

OMB Number: 3064-0143
Expiration Date: 09/30/2023

Federal Deposit Insurance Corporation

DECLARATION FOR DEFINED CONTRIBUTION PLAN

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 you
provide may be provided to appropriate Federal, state, local or foreign law enforcement authorities; to a court,
administrative tribunal, or a party in litigation; to contractors, agents and other third parties as authorized by law, and in
accordance with 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. 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.
PAPER 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 ½ hour 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
17th 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.

NOTE: 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).

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FDIC 7200/10 (11-21)

OMB Number: 3064-0143
Expiration Date: 09/30/2023

Federal Deposit Insurance Corporation

DECLARATION FOR DEFINED CONTRIBUTION PLAN
INSTRUCTIONS: The Federal Deposit Insurance Corporation completes Section I of this form, and the Depositor/Representative
completes Section II. The Depositor ID is provided by the Federal Deposit Insurance Corporation FDIC. Select "Email Form" button
to submit completed form, supporting documents, and required attachments to Depositorservices@fdic.gov or mail form and all
supporting documents to the Claims Department at 600 North Pearl Street, Suite 700, Dallas, TX 75201. For questions, contact
Depositor Claims Agent at 972-761-2112.
SECTION I - FINANCIAL INSTITUTION
1. Name

2. Closing Date

3. Account Number

4. Depositor ID

SECTION II - DECLARATION
5. The undersigned is the trustee or administrator for the

Plan (the “Plan”),

for which the above account(s) was (were) established at the above insured depository institution. (If the undersigned is not the
trustee or administrator for the Plan, please attach an explanation as to why the undersigned and not the administrator has
completed this form.)
6. The Plan is a defined contribution plan sponsored by

. Also, it is an

“employee benefit plan” as that term is defined in section 3(3) of the Employee Retirement Income Security Act of 1974 (29 U.S.C.
§ 1002).
7. The above account or accounts represent an investment of general Plan assets for the benefit of all participants in the Plan. The
accounts do not represent self-directed funds or segregated funds for particular participants. (If the accounts represent selfdirected funds or segregated funds for particular participants, in whole or in part, you should attach a separate report that reflects
(A) the names of the Plan participants for whom the accounts were held; and (B) the amount held in the accounts for each such
participant. Also, you should attach copies of the agreements that authorize these participants to direct funds into the accounts or
to serve as beneficiaries of the segregated funds in the accounts.)
8. On the closing date, the value of all general Plan assets (including but not limited to the deposits in the above account(s))
was

.

9. The insurance coverage of the deposits of an employee benefit plan is governed by 12 C.F.R. § 330.14. Under that section of the
FDIC's insurance regulations, the deposits must be divided into the following categories: (1) funds representing the “noncontingent interests” (as defined below) of the Plan participants; (2) funds representing the “contingent interests” of the Plan
participants; and (3) funds representing any “overfunding” of the Plan. In this case, the value of all general Plan assets (including
but not limited to the deposits in the above account(s)) can be divided as follows:
Combined dollar amount of participants' "non-contingent interests."
Dollar amount of contingent interests:
Dollar amount of overfunding:
10. On the closing date, the number of participants in the Plan was

FDIC 7200/10 (11-21)

.

OMB Number: 3064-0143
Expiration Date: 09/30/2023

11. In the case of a defined contribution plan, an employee's “non-contingent interest” is “deemed to be the employee's account
balance as of the date of default of the insured depository institution, regardless of whether said amount was derived, in whole or
in part, from contributions of the employee and/or the employer to the account.” 12 C.F.R. § 330.14(c)(1). Under this definition,
the participant with the largest “non-contingent interest” in the Plan on the closing date was
His/her account balance on the closing date was

.

.

12. Attach report reflecting all participants' account balances in the Plan as of the closing date. In this report, please include a
statement as to whether the given account balances accurately reflect the respective interests of the participants in the above
account(s). Attach report by selecting the "Email Form" button at the top right hand corner of form. If not, please provide an
explanation.

13. This declaration is made to induce the Federal Deposit Insurance Corporation to pay insurance covering the above account(s) to
the extent provided by law.
14. 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 or Administrator Name)

FDIC 7200/10 (11-21)

.

(Trustee or Administrator Signature)