7200.12 Declaration for Defined Benefit Plan

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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OMB NUMBER: 3064-0143

Federal Deposit Insurance Corporation

DECLARATION FOR DEFINED BENEFIT PLAN

EXPIRATION DATE: 08/31/2016

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

Financial Institution:      

Closing Date:      

Account Number(s):      

Customer Number:      

The undersigned is the trustee or administrator for the      

Plan (the "Plan"), for which the above account(s) was (were) established at the above insured depository institution. (If the undersigned is not the trustee or administrator for the Plan, please attach an explanation as to why the undersigned and not the administrator has completed this form.)

The Plan is a defined benefit plan sponsored by      

.

Also, it is an “employee benefit plan” as that term is defined in section 3(3) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. § 1002). Attached is a copy of the most recent actuarial report for the Plan (only required if the total balance of the account or accounts exceeds $250,000 or if there were any other accounts at the failed institution for other employee benefit plans sponsored by the same employer).

3. The above account or accounts represent an investment of general Plan assets for the benefit of all participants in the Plan. The accounts do not represent self-directed funds or segregated funds for particular participants. (If the accounts represent self-directed funds or segregated funds for particular participants, you should attach a separate report that reflects (A) the names of the Plan participants for whom the accounts were held; and (B) the amount held in the accounts for each such participant. Also, you should attach copies of the agreements that authorize these participants to direct funds into the accounts or to serve as beneficiaries of the segregated funds in the accounts.)

4. On the closing date, the value of all general Plan assets (including but not limited to the deposits in the above account(s))
was      	.

5. The insurance coverage of the deposits of an employee benefit plan is governed by 12 C.F.R. § 330.14. Under that section of the FDIC’s insurance regulations, the deposits must be divided into the following categories: (1) funds representing the “non-contingent interests” (as defined below) of the Plan participants; (2) funds representing the “contingent interests” of the Plan participants; and (3) funds representing any “overfunding” of the Plan. In this case, the value of all general Plan assets (including but not limited to the deposits in the above account(s)) can be divided as follows:

Combined dollar amount of participants’ “non-contingent interests”:	     
Dollar amount of contingent interests:	     
Dollar amount of overfunding:	     

6. On the closing date the number of participants in the Plan was      

.

7. In the case of a defined contribution plan, an employee’s “non-contingent interest” is “deemed to be the present value of the employee’s interest in the plan, evaluated in accordance with the method of calculation ordinarily used under such plan, as of the date of default of the insured depository institution. 12 C.F.R. § 330.14(c)(2). Under this definition, the participant with the largest

“non- contingent interest” in the Plan on the closing date was      	..
His/her percentage interest in the Plan on the closing date was      	..
This percentage interest was determined by dividing the participant’s “non-contingent interest” by the total Plan assets.

8. The figures given above are based upon the interest rate and mortality assumptions stated in the Plan.

8. The declaration is made to induce the Federal Deposit Insurance Corporation to pay insurance covering the above account(s) to the extent provided by law.

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

10.1I declare under penalty of perjury that the foregoing is true and correct. Executed on      

..

     
Name of Trustee or Administrator (Please print)			Signature of Trustee or Administrator

FDIC 7200/12 (8-13) Page 1

DECLARATION FOR DEFINED BENEFIT PLAN (Continued)

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 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. 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.

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