Form 7200.04 Declaration for Public Unit Deposit

OMB Number: 3074-0143

Expiration Date: 08/31/2016

Federal Deposit Insurance Corporation

DECLARATION FOR GOVERNMENT DEPOSIT

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

Financial Institution:      

C losing Date:      

A ccount Number:      

C ustomer Number:      

1. I am (We are) the official custodian(s) of       (the “Public Unit”), which is the owner of the referenced account at the closed institution. Under the FDIC’s regulation at 12 C.F.R. § 330.15, an “official custodian” is defined as a custodian with “plenary authority, including control, over funds owned by the public unit which the custodian is appointed or elected to serve. Control of public funds includes possession, as well as the authority to establish accounts for such funds in insured depository institutions and to make deposits, withdrawals, and disbursements of such funds.”

1 2 C.F.R. § 330.15(b)(1). I (We) have been appointed official custodian by statute, ordinance or      	.
     	.

A copy of the relevant statute, ordinance or other authority is attached. The funds in the account have been lawfully invested at the closed institution pursuant to statute, ordinance or       .

A copy of the relevant statute, ordinance or other authority is attached.

2. The account was owned by (check one of the following):

A. The United States of America

B. A state of the United States

C. A county

D. A municipality

E. The District of Columbia

F. The Commonwealth of Puerto Rico, the Virgin Islands, American Samoa, the Trust Territory of the Pacific Islands, Guam, or The Commonwealth of the Northern Mariana Islands, or any county or municipality thereof.

G. A “political subdivision” of a public unit mentioned in (B), (C), (D), (E) or (F) above. Under the FDIC’s regulation,

12 C.F.R. § 330.15, a “political subdivision” is defined to include “drainage, irrigation, navigation, improvement, levee, sanitary, school or power districts, and bridge or port authorities and other special districts created by state statute or compacts between the states.” 12 C.F.R. § 330.15(d). The term also includes any subdivision of a public unit mentioned in (B), (C), (D), (E) or (F) or any principal department of such public unit that satisfies the following criteria: “(1) The creation of which subdivision or department has been expressly authorized by the law of such public unit; (2) To which some functions of government have been delegated by such law; and (3) Which is empowered to exercise exclusive control over funds for its exclusive use.” Id.

H. An Indian Tribe (as defined in 25 U.S.C. § 1452(c))

FDIC 7200/04 (8-13) Page 1

DECLARATION FOR GOVERNMENT DEPOSIT (Continued)

3. To the best knowledge of the undersigned, the Public Unit does not have an ownership interest in any other accounts at the closed Institution whether established by the official custodian or any other person, except for the accounts listed here:

     

     

4. This declaration is made to induce the Federal Deposit Insurance Corporation to pay insurance covering the deposit to the extent that the deposit is covered by insurance.

5. This declaration, under penalty of perjury, is executed pursuant to 28 U.S.C. § 1746.

I (We) declare, under penalty of perjury, that the foregoing is true and correct.

Executed on:      

.

Signature of Official Custodian		Signature of Official Custodian
     		     
Title		Title

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 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 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 of information unless it displays a currently valid OMB control number.

FDIC 7200/04 (8-13) Page 2