143 - Voluntary Liquidation - Annual Report

OMB no. 1557-0014

Expiration date: See www.occ.gov

Voluntary Liquidation

Applicant

_____________________________________________________________________

Name Charter no.

_____________________________________________________________________

Current street address

_____________________________________________________________________

City County State Zip code

Parent Company Identifying Information (if applicable)

_____________________________________________________________________

Name

_____________________________________________________________________

Street

_____________________________________________________________________

City State Zip code

Contact Person

_____________________________________________________________________

Name Title

_____________________________________________________________________

Employer

_____________________________________________________________________

Street

_____________________________________________________________________

City State Zip code

_____________________________________________________________________

Telephone no. Fax no. E-mail address

Annual Report of Progress of Liquidation

Report of Progress of Liquidation Filed Pursuant to 12 CFR 5.48(e)(5)

All creditor claims, including any additional claims asserted during the period of advertisement for claims, (have, have not) been fully paid or assumed by an operating bank.

• Yes

• No

Amount of agent/committee members’ fee: $

Since the (original/last reported) appointment of the liquidating agent/committee, the shareholders have made the following changes:

Name and address of appointed agent Appointed to succeed Date

Aggregate book value of assets originally received by agent/committee: $

Cash originally received by agent/committee: $

TOTAL: $

Present book value of remaining unliquidated assets: $

Cash on hand: $

TOTAL: $

The following distribution to shareholders, if any, has been declared:

Date declared:

Distribution amount:

Percent of distribution:

If the bank had a trust department, show the disposition since liquidation.

Number of fiduciary accounts as of the liquidation start date:

Number of fiduciary accounts closed, transferred, or otherwise disposed of since the liquidation start date:

(Briefly summarize the progress of the liquidation during the past reporting year. Discuss the status of any pending litigation or court ordered liabilities and state the anticipated liquidation completion date. Explain what plans are in progress to complete the liquidation and state whether further distributions will be made to shareholders.)

This report of progress of liquidation and any attachments (schedules) are as of (date) and certified to be correct to the best of my knowledge and belief.

___________________________________________________________________

(Liquidating agent) (Correspondent for committee)

____________________________________________________________________

(Committee member)

____________________________________________________________________

(Committee member)

____________________________________________________________________

(Committee member)

_________________________________

Date signed

(If there is a liquidating committee, every member should sign.)

Enclosure:

• Most recent month end report of assets and liabilities

1