Application for Cancellation of Federal Reserve Bank Stock (for use by insolvent member banks)

FR 2087
OMB Number 7100-0042
Approval expires February 28, 2018
Page 1 of 1

FOR USE BY INSOLVENT MEMBER BANKS.

Board of Governors of the Federal Reserve System

Application for Cancellation of
Federal Reserve Bank Stock—FR 2087

Date of Application

I,

, of

having been duly appointed by

,

, Receiver of

Comptroller of the Currency, Court, or Proper State Official

Legal Name of Bank

City or Town

State

ABA Number (optional)

(Charter Number
), and as such having charge of the liquidation of the estate of said bank,
do hereby make application1 to the Federal Reserve Bank of
for the cancellation of
shares of stock of the Federal Reserve Bank heretofore issued to this bank and forming part of the
assets of its estate and for the refund of all moneys, securities, or other valuables due upon an accounting to the estate of this bank by the
said Federal Reserve Bank.
Receiver

}

State of
County of

ss:

The above application was subscribed before me this

day of
Day

,
Month

, and the
Year

person who signed the same is known to me to be the person who is described in such application as receiver.

Notary Public

1. When the application is made by a receiver (or other person, commission, or agency charged by law with the duty of winding up the affairs of the bank)
of a state member bank or trust company, it must be accompanied by a certified copy of the commission issued by the proper state official, or of the
order of court, appointing him or her as receiver of such bank or trust company.

This application should be sent to the FEDERAL RESERVE BANK of your district.
Public reporting burden for this collection of information is estimated to average 0.5 hours per response, including the time to gather and maintain data in the required form and to review
instructions and complete the information collection. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to Secretary, Board of Governors of the Federal Reserve System, Washington, DC 20551; and to the Office of Management and Budget, Paperwork Reduction Project (7100–
0042), Washington, DC 20503. The Federal Reserve may not conduct or sponsor, and an organization (or a person) is not required to respond to a collection of information unless it dis-

plays a currently valid OMB control number.
02/2015