7200.07 Declaration of Independent Activity for Unincorporated A

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.  Furnishing 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.  The information provided by individuals is protected by the Privacy Act, 5 U.S.C. 552a.  The information may be furnished to third parties as authorized by law or used according to any of the other routine uses described in the FDIC Insured Financial Institution Liquidation Records (FDIC-30-64-0013) System of Records.  A complete copy of this System of Records is available at http://www.fdic.gov/regulations/laws/rules/2000-4050.html#fdic200030--64--0013.   If you have questions or concerns about the collection or use of the information, you may contact the FDIC’s Chief Privacy Officer at [email protected]. 

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Federal Deposit Insurance Corporation

DECLARATION OF INDEPENDENT ACTIVITY

FOR UNINCORPORATED ASSOCIATION

INSTRUCTIONS: An executed copy of this Declaration of Independent Activity for Unincorporated Association must be submitted before an insurance determination can be made on your Account. Please be sure to attach to this

Declaration of Independent Activity for Unincorporated Association all of the documentation requested in Item 6.

F inancial Institution:      

Closing Date:      

Account Number:      

C ustomer Number:      

1. T he undersigned is       of      

(Title) (Name of Organization)

      (the “Accountholder”) and is responsible for: (Describe Duties)

     

     

2. Under the Federal Deposit Insurance Corporation’s (FDIC) regulations, an unincorporated association is deemed to exist for deposit insurance purposes whenever there is an association of two or more persons formed for some religious, educational, charitable, social or other noncommercial purpose. 12 C.F.R. § 330.12(c). The purpose of the Accountholder may be described as follows:

     

     

3. The source of funds for the above-listed Account was:

     

     

4. The members of the Accountholder are the following: (Do not complete if the number of members exceeds ten).

     

     

5. The officers of the Accountholder on the closing date were the following:

     

     

6. Attached are copies of the following: (1) the charter or bylaws of the Accountholder; and (2) evidence reflecting the tax-exempt status of the Accountholder.

7. Does the Accountholder have an ownership interest, directly or indirectly, in any other accounts at the closed institution?

Yes (Please provide account numbers):      

No

FDIC 7200/07 (8-13) Page 1

DECLARATION OF INDEPENDENT ACTIVITY FOR UNINCORPORATED ASSOCIATION (Continued)

8. The undersigned, or any one of them, has (have) been authorized to execute and deliver to the FDIC information concerning the above-referenced Account at the closed institution and to take any and all other actions and to execute any and all other documents in connection with the payment of insurance on such Account and to subrogate to the FDIC the Accountholder’s rights in such Account to the extent such Account is insured. If not applicable, please check box. Not Applicable

9. The declaration is made to induce the FDIC to pay insurance covering the Account to the extent that the Account is covered by insurance.

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

I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct.

E xecuted on:      

.

Signature

     

P rint Name

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 closes in accordance with the FDIC’s deposit insurance regulations. Public reporting burden for this collection of information is estimated to average ½ 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 7200/07 (8-13) Page 2