7200/04 Declaration for Government Deposit

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

Federal Deposit Insurance Corporation

DECLARATION FOR GOVERNMENT DEPOSIT

PRIVACY ACT STATEMENT
The Federal Deposit Insurance Act (12 U.S.C. §§ 1819, 1821, and 1823) authorize the collection of this information. The
FDIC will use the information to respond to your request for assistance regarding the receivership estate of a failed
financial institution. Furnishing this information is voluntary but failure to provide the requested information in whole or in
part may delay or prevent the requested assistance or other response to your request. 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.

PAPERWORK REDUCTION ACT NOTICE
The information collected is required for 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. 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 7200/04 (1-22)

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

Federal Deposit Insurance Corporation

DECLARATION FOR GOVERNMENT DEPOSIT
INSTRUCTIONS: The Depositor/Representative completes Section II of this form and an Federal Deposit Insurance
Corporation (FDIC) representative completes Section I. The FDIC will provide the Depositor ID (ID is an internal,
system-generated identifier). Select the Attach File icon to attach supporting and required documents to form. Submit
forms electronically or by mail to the Claims Department at 600 North Pearl Street, Suite 700, Dallas, TX 75201. (Include
all supporting documents at the same time). For questions, contact Depositor Claims Agent at 972-761-2112 or at
Depositorservices@fdic.gov.
SECTION I - FINANCIAL INSTITUTION
1. Name

2. Closing Date

3. Account Number

4. Depositor ID

SECTION II - DECLARATION
5. I am (We are) the official custodian(s) of      

(the “Public Unit”), which is

the owner of the referenced account at the closed institution. Under the FDIC's regulation at 12 C.F.R. § 330.15, an
“official custodian” is defined as a custodian with “plenary authority, including control, over funds owned by the public
unit which the custodian is appointed or elected to serve. Control of public funds includes possession, as well as the
authority to establish accounts for such funds in insured depository institutions and to make deposits, withdrawals,
and disbursements of such funds.” 12 C.F.R. § 330.15(b)(1). I (We) have been appointed official custodian by
statute, ordinance or      

.

.

The funds in the account have been lawfully invested at the closed institution pursuant to statute, ordinance
or

. Attach a copy of the relevant statute, ordinance or other

authority to the email when you select the "Email Form" button at the top of the form.
6. The account was owned by:
A. The United States of America
B. A state of the United States
C. A county
D. A municipality
E. The District of Columbia
F. The Commonwealth of Puerto Rico, the Virgin Islands, American Samoa, the Trust Territory of the Pacific
Islands, Guam, or The Commonwealth of the Northern Mariana Islands, or any county or municipality thereof.
G. A “political subdivision” of a public unit mentioned in (B), (C), (D), (E) or (F) above. Under the FDIC's
regulation, 12 C.F.R. § 330.15, a “political subdivision” is defined to include “drainage, irrigation, navigation,
improvement, levee, sanitary, school or power districts, and bridge or port authorities and other special districts
created by state statute or compacts between the states.” 12 C.F.R. § 330.15(d). The term also includes any
subdivision of a public unit mentioned in (B), (C), (D), (E) or (F) or any principal department of such public unit
that satisfies the following criteria: “(1) The creation of which subdivision or department has been expressly
authorized by the law of such public unit; (2) To which some functions of government have been delegated by
such law; and (3) Which is empowered to exercise exclusive control over funds for its exclusive use.”
H. An Indian Tribe (as defined in 25 U.S.C. § 1452(c))
FDIC 7200/04 (1-22)

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

7. To the best knowledge of the undersigned, the Public Unit does not have an ownership interest in any other accounts
at the closed Institution whether established by the official custodian or any other person, except for the accounts
listed here:

8. This declaration is made to induce the Federal Deposit Insurance Corporation to pay insurance covering the deposit
to the extent that the deposit is covered by insurance.
9. This declaration, under penalty of perjury, is executed pursuant to 28 U.S.C. § 1746.

I (We) declare, under penalty of perjury, that the foregoing is true and correct. Executed on:

(Official Custodian Signature)

(Official Custodian Signature)

(Title)

(Title)

FDIC 7200/04 (1-22)

.

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