7200/26 Depositor Interview

OMB NUMBER: 3064-0143

EXPIRATION DATE: 08/31/2020

Federal Deposit Insurance Corporation

DEPOSITOR INTERVIEW FORM

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.

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.

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Federal Deposit Insurance Corporation

DEPOSITOR INTERVIEW FORM

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

Financial Institution:      

Fund Number:      

Depositor Name:      

Customer ID Number:      

Telephone Number:      

Email Address:      

FACTS Case Number:      

1. Verify the address and last four digits of the Taypayer Identification Number (TIN/SSN) on the account. If the person does not sign on the account, you may need a power of attorney from the account owner.

Address		TIN
     		     

2. Access the Account Ownership Summary Statement (AOSS) and confirm the depositor’s ownership in all deposit accounts listed. If any accounts owned are missing from the AOSS, determine if they need to be added to the depositor’s case file and aggregated with the listed depositor accounts.

3. Are all account owners living? If any account holders are deceased, indicate name and date of death.

Name		Date of Death
     		     
     		     
     		     

4. Does the Depositor have accounts in the REV-ITF, REV-LIV, IRR, BUS-ESC, GOV-ESC, or EBP insurance categories? If yes, the depositor will need to provide documentation and complete the appropriate Declaration. Has documentation been provided?

Yes No (Ask depositor to email, fax, or mail as soon as possible.)

5. Is the Depositor holding any official items of the bank, e.g., Cashier’s Checks, Money Orders, Interest Checks, or Loan Disbursement Checks? If yes, the official item(s) may need to be aggregated with the Depositor’s other accounts to determine insurance coverage.

Yes No

6. Does the Depositor have a loan with the bank?

Yes (Obtain list of loan obligations from the Asset Team or Asset Disposition Department to determine mutuality.)

• If mutuality exists, the depositor may elect to offset insured and/or uninsured funds against the deposit. Refer the depositor to the Asset Disposition Department to discuss the matter in detail. (Explain to the depositor the advantages of electing to offset versus remaining uninsured).

• If mutuality does not exist or if the depositor elects not to offset, an RC transaction will be posted to the account and a Notice of Insurance Determination Letter will be issued.

No (Depositor does not have a loan.)

Is the Depositor a guarantor on a loan held by the failed bank?

Yes (Refer the depositor to the Asset Team or the Asset Disposition Department to discuss this matter in detail.)

No

FDIC 7200/26 (5-17)

7. Issuance of the Notice of Insurance Determination Letter. Explain that the depositor has an approved claim against the Receivership for uninsured funds and may receive periodic dividend distributions, paid on a pro-rata basis, along with the other approved deposit claimants.

8. Discuss with the depositor any FDIC holds or debits posted to their accounts and the impact on their ability to transact business on these accounts.

Name Claims Agent (Please print)		Date of Interview
     		     
Signature of Claims Agent:
Determination: (Check one) Fully Insured Uninsured Partially Insured

EXPLAIN INSURANCE DETERMINATION:
     
COMMENTS AND NOTES (Date and initial):
     
Date	Initial
     

FDIC 7200/26 (5-17) Page 2