Form 7200/09 Declaration for Testamentary Deposit

OMB NUMBER: 3064-0143

EXPIRATION DATE: 07/31/2011

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 FDIC will use the information to assist in the determination of deposit insurance coverage and/or the payment of deposit insurance on deposits of the closed financial institution. The FDIC may disclose this information: 1) to other federal or state financial institution regulatory agencies, to the financial institution which acquired the deposit accounts of the closed financial institution, if any, and to contractors to assist in the determination and/or payment of deposit insurance on deposits of the closed financial institution; 2) to appropriate Federal, State or local agency or responsible authority, to the extent that disclosure is necessary and pertinent for investigating or prosecuting a violation of or for enforcing or implementing a statute, rule, regulation or order, when the information indicates a violation or potential violation of law, whether civil, criminal or regulatory in nature, and whether arising by any statute, or by regulation, rule or order issued pursuant thereto; 3) to a court, magistrate, or administrative tribunal in the course of presenting evidence, including disclosure to counsel or witnesses in the course of civil discovery, litigation, or settlement negotiations or in connection with criminal law proceedings, when the FDIC is a party to the proceeding or has a significant interest in the proceeding and the information is determined to be relevant and necessary; or 4) in accord with any other routine use appropriate for the FDIC’s Insured Financial Institution Liquidation Records, # 30-64-0013. Submitting this information to the FDIC is voluntary. Failure, however, to submit all of the information requested and to complete the form entirely could delay or preclude the determination of deposit insurance coverage and/or the payment of deposit insurance on deposits of the closed financial institution.

PAPERWORK REDUCTION ACT NOTICE

The information collected I 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 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 Paper Reduction Act Clearance Officer, Legal, Division room MB-3082, Federal Deposit Insurance Corporation, 550 17^th Street, N.W., Washington, D.C. 20429. 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 FDIC 7200/09

Federal Deposit Insurance Corporation

DECLARATION FOR TESTAMENTARY DEPOSIT

INSTRUCTIONS: Please type or print all information legibly, date, and sign.

F inancial Institution:      

Closing Date:      

A ccount Number:      

C ustomer Number:      

1. The undersigned is (are) Grantor(s) of the above account (the “Account”) and constitute all of the persons who own all of the

funds in the Account according to the following percentages:

	NAME OF GRANTOR(S)		PERCENTAGE OF FUNDS CONTRIBUTED TO THIS ACCOUNT
(A)	     		     
(B)	     		     
			Note: Percentages must equal 100%

2. I (We) further declare that my (our) intent in establishing the Account was to provide that the funds in the Account, upon

My (our) death would be owned by the beneficiaries identified below.

3. The beneficiaries of the account are as follows:

BENEFICIARY		BENEFICIARY TYPE (Individual/Charity/ Non-Profit)	IF INDIVIDUAL, IS THE PERSON LIVING? (Check applicable box)		IF CHARITY OR NON-PROFIT, IS IT RECOGNIZED BY THE IRS? (Check applicable box)
			Yes	No	Yes	No
     		     
     		     
     		     
     		     
     		     
     		     
     		     
     		     
     		     

4. If the funds in this Account were placed by you as grantors 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. Note: Be sure to attach this Declaration to the copy of the Trust.

5. 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.

6. 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		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).