7200/07 Declaration of Independent Activity for Unincorporated A

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

Federal Deposit Insurance Corporation

DECLARATION OF INDEPENDENT ACTIVITY
FOR UNINCORPORATED ASSOCIATION
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.

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 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 7200/07 (1-22)

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

Federal Deposit Insurance Corporation

DECLARATION OF INDEPENDENT ACTIVITY
FOR UNINCORPORATED ASSOCIATION
INSTRUCTIONS: An executed copy of this Declaration of Independent Activity for Unincorporated Association must be submitted
before an insurance determination can be made on your Account. 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. The undersigned is

of

(Title)
(the "Accountholder") and is responsible for:

(Name of Organization)

Describe Duties

6. Under the Federal Deposit Insurance Corporation's (FDIC) regulations, an unincorporated association is deemed to exist for
deposit insurance purposes whenever there is an association of two or more persons formed for some religious, educational,
charitable, social or other noncommercial purpose. 12 C.F.R. § 330.12(c). The purpose of the Accountholder may be described as
follows:

7. The source of funds for the above-listed Account was:

8. The members of the Accountholder are the following: (Do not complete if the number of members exceeds ten.)

9. The officers of the Accountholder on the closing date were the following:

FDIC 7200/07 (1-22)

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

10. Attach the following after you select the "Email Form" button at the top right hand corner of form:
a. The charter or bylaws of the Accountholder; and
b. Evidence reflecting the tax-exempt status of the Accountholder.
11. Does the Accountholder have an ownership interest, directly or indirectly, in any other accounts at the closed institution?
Yes

No

If Yes, provide Account Numbers:

12. The undersigned, or any one of them, has (have) been authorized to execute and deliver to the FDIC information concerning the
above-referenced Account at the closed institution and to take any and all other actions and to execute any and all other
documents in connection with the payment of insurance on such Account and to subrogate to the FDIC the Accountholder's rights
in such Account to the extent such Account is insured. If not applicable, please check box.
Not Applicable
13. The declaration is made to induce the FDIC to pay insurance covering the Account to the extent that the Account is covered by
insurance.
14. This declaration, under penalty of perjury, is executed pursuant to 28 U.S.C. § 1746.

I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct.
Executed on:

(Signature)

(Print Name)

FDIC 7200/07 (1-22)

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