7200.14 Declaration for Health and Welfare Plan

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.

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Federal Deposit Insurance Corporation

DECLARATION FOR HEALTH AND WELFARE PLAN

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

Financial Institution:      

C losing Date:      

A ccount Number:      

Customer Number:      

1. The undersigned is the trustee or administrator for the      

Plan (the “Plan”),

f or 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.)

2. The Plan is a welfare plan that provides medical, dental, life insurance or similar benefits to employees. 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). The Plan was sponsored by      

.

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. If you have reported any of the Plan assets as representing “non-contingent interests,” please attach an explanation. For deposit insurance purposes, a “non-contingent interest” is defined as “an interest capable of determination without evaluation of contingencies except for those covered by the present worth tables and rules of calculation for their use set forth in § 20.2031-7 of the Federal Estate Tax Regulations (26 CFR 20.2031-7) or any similar present worth or life expectancy tables as may be published by the Internal Revenue Service.” 12 C.F.R. § 330.14(f)(4).

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

9. 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 or Administrator Name (Please print)		Trustee or Administrator Signature

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).