7200/08 Declaration for Joint Ownership Deposit

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

Federal Deposit Insurance Corporation

DECLARATION FOR JOINT OWNERSHIP 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 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 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 7200/08 (1-22)

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

Federal Deposit Insurance Corporation

DECLARATION FOR JOINT OWNERSHIP 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. We,

declare that we are the owners of all of the funds in the

above account (the “Account”).
6. We further declare that we own these funds jointly (as joint tenants with right of survivorship, as tenants in common, or as tenants
by the entirety).
7. We further declare we own the funds according to the following percentages:
Name

Percentage of Funds Contributed

NOTE: The information above (percentage of funds contributed by each co-owner) may or may not be used by the FDIC in calculating
the insurance coverage of the Account. In the case of qualifying joint accounts held as tenants in common, the interests of the coowners are deemed equal unless otherwise stated in the depository institution's deposit account records. 12 C.F.R. § 330.9(e).
8. If any owner is deceased, complete the following.
Name

Date of Death

9. Were the funds in this Account placed by (i) a trustee under a written trust agreement other than the account signature card, (ii) an
agent, or (iii) attorney-in-fact?

Yes

No

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:

FDIC 7200/08 (1-22)

.

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

FDIC 7200/08 (1-22)

(Co-Owner Name)

(Co-Owner Signature)

(Co-Owner Name)

(Co-Owner Signature)

(Co-Owner Name)

(Co-Owner Signature)

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