7200/15 Declaration for Plan and Trust

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

Federal Deposit Insurance Corporation

DECLARATION FOR PLAN AND TRUST

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.
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FDIC 7200/15 (1-22)

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

Federal Deposit Insurance Corporation

DECLARATION FOR PLAN AND TRUST
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. The undersigned is (are) trustee(s) of the Plan and Trust (“Plan and Trust”) for which Account Number      
(the “Account”) was established at

.

6. The names of all of the trustee(s) of the Plan and Trust on the closing date were:
Name(s) of Trustee(s)

7. Attach the true, exact, and complete copy of the following:

a. The pages of the Plan appointing the trustees and showing the trustees' signatures;
b. Documents evidencing the Plan appointing the trustees;
c. The Plan trust;
d. The IRS letter confirming the adoption of the Plan; and
e. The list of participants showing their interest in the Plan.
8. Select one.
There is only one participant in the Plan; or
There is more than one participant in the Plan.
9. The trustees, or any one of them, have the authority under the Plan and Trust to execute, on behalf of the Trust, this declaration
and any and all other documents which the Federal Deposit Insurance Corporation may require to be executed in connection with
the payment of insurance on the Account and to bind the Trust by his or her action. If not applicable, select check box.
Not Applicable

FDIC 7200/15 (1-22)

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

10. This declaration is made to induce the Federal Deposit Insurance Corporation to pay insurance covering the Account, to the
extent 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)

.

(Trustee or Administrator Signature)

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).

FDIC 7200/15 (1-22)

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