7200/05 Declaration for Trust

OMB NUMBER: 3064-0143

EXPIRATION DATE: 07/31/2008

Federal Deposit Insurance Corporation

DECLARATION FOR TRUST

INSTRUCTIONS: Please type or print all information legibly, date, and sign. See page 2 for the Paperwork Reduction Act Notice.

F inancial Institution:      

Closing Date:      

Account Number:      

G roup Number:      

Revocable Trust

Irrevocable Trust

1. The undersigned is (are) trustee(s) of the attached Trust (the “Trust”) for which the above-referenced account(s) (the “Account(s)”) was/were established.

2. The names of all of the trustee(s) of said Trust on the closing date were:

     

     

The attached is a true, exact and complete copy of the Trust, as in effect on the closing date.

3. The settlor(s)/grantor(s) of said Trust and their respective contributions are:

NAME	PERCENTAGE OF FUNDS
(A)      	     
(B)      	     

100%

If a settlor/grantor is deceased, please give the name and date of the death of the settlor/grantor.

     		     
Name		Date of Death

4. If the Trust is revocable, list the beneficiaries of the Trust and the relationship of each of them to each of the above-named settlers/grantors:

NAME OF BENEFICIARY	RELATIONSHIP TO (A)	RELATIONS TO (B)
     	     	     
     	     	     
     	     	     
     	     	     
     	     	     

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

NAME	DATE OF DEATH
     	     
     	     
     	     

5. The undersigned, or any one of them [STRIKE IF NOT APPLICABLE], has (have) the authority under the Trust to execute, on behalf of the Trust, this Declaration, the claim form and all other documents which the Federal Deposit Insurance Corporation (“FDIC”) may require to be executed in connection with the payment of insurance on the Account(s) and to bind the Trust by his or her action.

6. This declaration is made to induce the Federal Deposit Insurance Corporation to pay insurance covering the Account(s), to the extent the Account(s) is (are) covered by insurance.

FDIC 7200/05 (10-05) Page 1

DECLARATION FOR TRUST (Continued)

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:      .

     		     
Trustee		Trustee

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

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).

PAPERWORK REDUCTION ACT NOTICE

The information collected is required for the determination of insured deposits when a financial institution close 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, 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 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. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection unless it displays a currently valid OMB control number.

FDIC 7200/05 (10-05) Page 2