7200.9 Declaration for Testamentary Deposit

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]. 

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 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, 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.

Page down to access form FDIC 7200/09

Federal Deposit Insurance Corporation

DECLARATION FOR TESTAMENTARY DEPOSIT (IN TRUST FOR OR PAYABLE ON DEATH)

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

F inancial Institution:      

Closing Date:      

A ccount Number:      

Customer 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:

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

NOTE: The information above (percentage of funds contributed by each co-owner) may or may not be used by the FDIC in calculating the insurance coverage of the Account. In the case of qualifying joint accounts held as tenants in common, the interests of the co-owners are deemed equal unless otherwise stated in the depository institution’s deposit account records.

12 C.F.R. § 330.10(f).

If any grantor is deceased, complete the following:

Name		Date of Death
           		     
     		           

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 agreement.

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.

FDIC 7200/09 (8-13) Page 1

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).

FDIC 7200/09 (8-13) Page 2