Form NCUA: 7250 NCUA: 7250 Proof Of Claim

NCUA 7250

PROOF OF CLAIM

(1) Claimant’s SSN/Tax ID #

(2) The undersigned,

(Printed name of person completing and signing this proof of claim)

states (3) _________________________________________, ________________, ____ now in

(Name of the Credit Union) (City) (State)

liquidation, is indebted to

(4) in the sum of

(Name of the Claimant)

_{(5) $ __________________________}

(6) Description of claim

I have a written contract relating to this claim. circle one: no / yes (please attach)

The undersigned further states that no part of this debt has been paid, the Claimant has given no endorsement or assignment of the debt or any part thereof, and there is no set-off or counterclaim, or other legal or equitable defense to this claim or any part thereof.

(7) Signature _

(Signature of Person making the Claim) (Title)

(8) Firm (9) Date ___________

(If applicable)

(10) Mailing Address _________________________________________________________

City/State/ZIP Code _________________________________________________________

(11) Telephone Number

CRIMINAL PENALTY FOR PRESENTING A FRAUDULENT CLAIM OR MAKING FALSE STATEMENTS: claimant may be fined not more $250,000 or imprisoned for not more than 5 years or both. See 18 U.S.C §287.

CIVIL PENALTY FOR PRESENTING FRAUDULENT CLAIM: claimant may be liable to the United States Government for a civil penalty of not less than $5,000 and not more than $10,000, plus 3 times the amount of damages which the Government sustains because of claimant’s acts. The claimant may also be liable for the costs of a civil action brought to recover such penalty or damages. See 31 U.S.C. §3729.

The FEDERAL CREDIT UNION ACT authorizes the collection of this information. We will use the information to assist in the determination of your claim(s) against the credit union. We may routinely disclose this information as described in our Asset Management and Assistance Center’s system of records notice (SORN) and in Appendix A of our Privacy Act SORN. This information is available on our website at www.NCUA.gov. You do not have to submit this information to the NCUA. Submitting this information to the NCUA is voluntary. If you omit information, however, you could delay or preclude our ability to determine the validity of your claim(s).

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.

PRIVACY ACT STATEMENT: Page Content

The solicitation and collection of this information is authorized by 15 U.S.C. § 57a(f) and 12 U.S.C. 1 et seq. The information is solicited to provide the National Credit Union Administration (NCUA) with data that is necessary and useful in reviewing requests received from individuals for assistance in their interactions with federal credit unions. The provision of requested information is voluntary. However, without such information, the ability to complete a review or to provide requested assistance may be hindered. It is intended that the information obtained through this solicitation will be used within the NCUA and provided to the federal credit union that is the subject of the complaint or inquiry. Additional disclosures of such information may be made as required by law.

(12) Email

GENERAL INFORMATION AND INSTRUCTIONS FOR COMPLETING

THE PROOF OF CLAIM FORM

This form is being sent to you in the event the failed institution owed you funds for services rendered or goods purchased prior to the date the credit union was closed. If the institution does not currently owe you any money, it is not necessary for you to complete this form.

The following blanks must be completed in order for your Proof of Claim to be considered: (The numbers correspond with those located on the proof of claim form.)

1. Claimant’s SSN/Tax ID #. The claimant’s tax identification number (if a company) or social security number (if an individual).

2. The undersigned. The printed name of the person making the claim and signing the form.

3. Credit Union Name, City, State. The name of the credit union the claim is being made against, including the city and state the credit union was located prior to liquidation.

4. Name of Claimant. The person or entity making the claim against the credit union.

5. Amount of the claim. The dollar amount of the claim. This amount should NOT include interest or late fees accrued since institution closing.

6. Description of claim. Detailed description of what is being claimed (i.e., the invoice number, type of service being claimed, account number, etc.). Additional information may be attached. Below this box, please indicate if you have a written contract.

7. Signature and Title. Signature and title (if applicable) of the person making claim, it should be the person named in (2).

8. Firm. If you are filing this claim on behalf of a business entity, please enter the name of the firm (if applicable).

9. Date. Date the form is signed.

10. Mailing Address. The address (including City, State and Zip code) of the claimant.

11. Telephone Number. The telephone number of the claimant.

12. Email. The email address of the claimant (if applicable)

REQUIRED DOCUMENTATION

• Claims for Goods Purchased by the Former Institution: You must forward a copy of the purchase order or other correspondence from the institution requesting the goods, a copy of your invoice and a receipt signed by the institution indicating that the goods were received.

• Claims for Services Rendered: You must forward a copy of the correspondence or signed initial contract sent by the institution to request your services and an invoice. In the case of legal fees, an itemized invoice must be sent indicating your prorated charges. For appraisal services, submit proof the appraisal was completed.