7200.15 Declaration for Plan and Trust

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 FOR PLAN AND TRUST

INSTRUCTIONS: Please type or print all information legibly and sign. Staple this Declaration to the copy of the relevant pages of the Plan and Trust, adoption agreement, or the IRS letter.

Financial Institution:      

C losing Date:      

Account Number:      

Customer Number:      

The undersigned is (are) trustee(s) of the Plan and Trust (“Plan and Trust”) for which Account Number      
( the “Account”) was established at      	.

2. The names of all of the trustee(s) of the Plan and Trust on the closing date were:

Names of Trustees

     

     

     

3. The Attached is a true, exact, and complete copy of:

a. The pages of the Plan appointing the trustees and showing the trustees’ signatures, and

b. Any one of:

(1) The Plan or Trust,

(2) The most recent determination letter issued by the Internal Revenue Service with respect to the Plan, or

(3) The adoption agreement if the Plan was adopted from a master or prototype plan and in effect on the

closing date.

4. Please check the applicable choice. There is only one or more than one participant in the Plan.

5. The trustees, or any one of them, have the authority under the Plan and Trust to execute, on behalf of the Trust, this declaration and any and all other documents which the Federal Deposit Insurance Corporation may require to be executed in connection with the payment of insurance on the Account and to bind the Trust by his or her action. If not applicable, check box. Not applicable

6. This declaration is made to induce the Federal Deposit Insurance Corporation to pay insurance covering the Account, to the extent the Account is covered by insurance.

7, 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:      

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Signature of Trustee		Signature of Trustee

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 ACTION 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. An agency may not conduct or respond to, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.