7200/10 – Declaration for Defined Contribution 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 purpose for collecting this information is to support the determination of deposit
insurance coverage and/or the payment of deposit insurance on deposits of the closed financial institution.
Furnishing this information is voluntary but failure to provide the requested information in whole or in part may
delay or prevent 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, including law enforcement authorities, 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 www.fdic.gov/about/privacy/index.html. 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].

Page down to access form FDIC 7200/10

OMB NUMBER: 3064-0143
EXPIRATION DATE: 05/31/2017

Federal Deposit Insurance Corporation

DECLARATION FOR DEFINED CONTRIBUTION PLAN
INSTRUCTIONS: Please type or print all information legibly, date, and sign. See page 2 for the Paperwork Reduction Act Notice.
Financial Institution:
Closing Date:
Account Number:
Customer Number:
1.

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.)

2.

The Plan is a defined contribution 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).

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, in whole or in part, 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 employee’s account
balance as of the date of default of the insured depository institution, regardless of whether said amount was derived, in whole or
in part, from contributions of the employee and/or the employer to the account.” 12 C.F.R. § 330.14(c)(1). Under this definition,
the participant with the largest “non-contingent interest” in the Plan on the closing date was
.
His/her account balance on the closing date was
.

8.

Attached is a report reflecting all participants’ account balances in the Plan as of the closing date. In this report, please
include a statement as to whether the given account balances accurately reflect the respective interests of the participants in
the above account(s). If not, please provide an explanation.

9.

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.

FDIC 7200/10 (5-14) Page 1

.

DECLARATION FOR DEFINED CONTRIBUTION PLAN (Continued)
10. 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).

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 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 17th 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.
FDIC 7200/10 (5-14) Page 2