7200/26 Depositor Interview

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

Federal Deposit Insurance Corporation

DEPOSITOR INTERVIEW

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. 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.
Page down to access form 7200/26

FDIC 7200/26 (1-22)

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

Federal Deposit Insurance Corporation

DEPOSITOR INTERVIEW
INSTRUCTIONS: The Federal Deposit Insurance Corporation Claims Agent completes this form.
SECTION I - FINANCIAL INSTITUTION
1. Financial Institution Name

2. Fund Number

3. Case Number

4. Depositor ID

5. Depositor Name

6. Telephone

7. Email

SECTION II - INTERVIEW
8. 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/SSN

9. 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.
10 Are all account owners living? If any account holders are deceased, indicate name and date of death.
Name

Date of Death

11. Does the Depositor have accounts in the REV-ITF, REV-LIV, IRR, BUS-ESC, GOV-ESC, or EBP insurance categories?
Yes
No
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.)

12. Is the Depositor holding any official items of the bank, e.g., Cashier's Checks, Money Orders, Interest Checks, or Loan
Yes
No
Disbursement Checks?
The official item(s) may need to be aggregated with the Depositor's other accounts to determine insurance coverage.
13. Does the Depositor have a loan with the bank?
Yes (Refer the depositor to the Asset Department to discuss this matter in detail.)
No
14. 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.
15. 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.

FDIC 7200/26 (1-22)

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

SECTION III - CLAIMS AGENT REVIEW
16. Comments

17. Name

FDIC 7200/26 (1-22)

18. Signature

19. Date of Interview

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