7200/05 Declaration for Revocable Trust

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.

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Federal Deposit Insurance Corporation

DECLARATION FOR REVOCABLE 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:      

C ustomer Number:      

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:

     

     

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

NAME	PERCENTAGE OF FUNDS
(A)      	     
(B)      	     

100%

     		     
Name		Date of Death

4. List the beneficiaries of the Trust :

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
     		     
     		     
     		     
     		     
     		     
     		     
     		     
     		     
     		     

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.

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DECLARATION FOR REVOCABLE 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 (11-09) Page 2