Form 7200/03 Declaration for Testamentary Deposit

OMB NUMBER: 3064-0143

EXPIRATION DATE: 07/31/2008

Federal Deposit Insurance Corporation

DECLARATION FOR TESTAMENTARY DEPOSIT

(SINGLE GRANTOR)

INSTRUCTIONS: Please type or print all information legibly, date, and sign. See below for the Paperwork Reduction Act Notice.

Financial Institution:      

C losing Date:      

A ccount Number:      

G roup Number:      

1. I ,       , declare that I am the Grantor of the above account

(Print or type name)

(the “Account”) and own all of the funds in the Account.

2. I further declare that my intent in establishing the Account was to provide that the funds in the Account, upon my death, would be owned by the beneficiaries identified below.

3. The beneficiaries of the Account and the relationship of each of them to me are as follows:

NAME OF BENEFICIARY	RELATIONSHIP TO ME
     	     
     	     
     	     
     	     
     	     

4. Each of the above-named beneficiaries is presently living. If any beneficiary is deceased, please indicate name and date of death:

     

5. If the funds in this Account were placed by you as grantor under a written trust agreement, other than the account signature card, attach a true, exact and complete copy of the trust agreement as in effect on the closing date.

6. 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.

7. 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:      .

_____________________________________________

Signature of Grantor

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).

Note: Please be sure to attach this Declaration to the copy of the Trust Agreement.

PAPERWORK REDUCTION ACT NOTICE

The information collected is required for the determination of insured deposits when a financial institution closes in accordance to Deposit Insurance Rules and Regulations. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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 Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17^th Street, N.W., Washington, D.C. 20429, and the Office of Management and Budget, Paperwork Reduction Project (3064-0143), Washington, D.C. 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.

FDIC 7200/03 (10-05)