7200/18 – Declaration for Irrevocable 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 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].

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Federal Deposit Insurance Corporation

DECLARATION FOR IRREVOCABLE TRUST

INSTRUCTIONS: Please type or print all information legibly, date, and sign. See page 2 for the Paperwork Reduction Act Notice.

F inancial Institution:      

Closing Date:      

Account Number:      

C ustomer Number:      

1. The undersigned is (are) Trustee(s) of the Trust (the “Trust”) for which the above-referenced account(s) (the “Account(s)”) was/were established. The documents creating said Trust are attached to this declaration.

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

     

     

3. The settlor(s)/grantor(s) of said Trust and their respective contributions are:

NAME	PERCENTAGE OF FUNDS
(A)      	     
(B)      	     

100%

If a grantor is deceased, please complete the following:

     		     
Name		Date of Death

4. List the beneficiaries of the Trust:

BENEFICIARY		IF INDIVIDUAL, IS THE PERSON LIVING? (Check applicable box)
		YES	NO
     
     
     
     
     
     
     
     
     

5. The undersigned, or any one of them has (have) the authority under the Trust to execute, on behalf of the Trust, this Declaration 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(s) and to bind the Trustee by his or her action.

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

FDIC 7200/18 (5-14) Page 1

DECLARATION FOR IRREVOCABLE TRUST (Continued)

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:      

.

Trustee Signature		Trustee Signature

     		     
Trustee Name (Please print)		Trustee Name (Please print)

Note: Please be sure to attach the Trust documents to this Declaration.

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 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.

FDIC 7200/18 (5-14) Page 2