7200/11 Declaration for IRA/KEOGH Deposit

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

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.

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 1/2 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. 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.

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 7200/11 (11-21)

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

Federal Deposit Insurance Corporation

DECLARATION FOR IRA/KEOGH DEPOSIT
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). Submit completed forms to
Depositorservices@fdic.gov by selecting the "Email Form" button 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 deposit referenced above (the “Account”) was made in connection with the following type of retirement plan (Select 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.
6. 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.)
7. The undersigned is employed by the trustee or administrator in the following capacity:

8. The owner of the Account is

.
(Name of Owner)

9. 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.)
10. 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.
11. 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 7200/11 (11-21)

.

(Trustee or Administrator Signature)