Form 7200/24 Claimant Verification

PRIVACY ACT STATEMENT

The Federal Deposit Insurance Act (12 U.S.C. §§ 1819, 1821, and 1822), 12 C.F.R. Part 330, and Executive Order 9397, as amended, 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].

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.

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OMB NUMBER: 3064-0143

EXPIRATION DATE: 05-31-2017

Federal Deposit Insurance Corporation

CLAIMANT VERIFICATION

INSTRUCTIONS: Please complete this form if you have an insured deposit which remains unclaimed and/or an outstanding dividend check (“Funds”) associated with the Failed Financial Institution identified below. Please provide a copy of your driver’s license and copies of any information that would help us promptly identify your account. If you are claiming funds on behalf of the account owner please contact [email protected] for additional documentation requirements.

NOTE: FDIC will not collect any personal information about individuals except when specifically and knowingly provided by such individuals. Examples of such information are: name, address, e-mail address, phone number, etc. Your submitted information is for internal use only and will not be distributed to any other parties. We will not sell, rent, or loan any identifiable information regarding clients to any third party. Any information you give us is held with utmost care and security, and will not be used in ways to which you have not consented.

Name of Closed Bank Financial Institution:      

City and State of Financial Institution:      

FDIC Reference Number:      

Account Owner Name:      

Name (If different than Account Owner):      

Current Home Address:      

City:      

State:      

ZIP Code:      

Address on Account (If different than above):      

City:      

State:      

ZIP Code:      

Telephone Number:      

Social Security Number/Tax ID Number:      

Email Address:      

ACKNOWLEDGMENT

State of:      

County of:      

I,      		, affirm that I am the Fund Owner or I am claiming funds on behalf of the Fund Owner
	indicated above.

I understand that presenting a false or fraudulent claim, in whole or in part, to the Federal Deposit Insurance Corporation may subject me to criminal and/or civil penalties as provided for in 18 U.S.C. §287 and 31 U.S.C. §3729, respectively.

Signature of Account Owner or Claimant

SUBSCRIBED AND SWORN TO BEFORE ME, this     

day of      

,     

			     
Signature of Notary Public			Printed Name of Notary Public

MY COMMISSION EXPIRES:

Please mail completed, notarized form to: FDIC

Attention: Unclaimed Funds

1601 Bryan Street

Dallas, TX 75201

FDIC 7200/24 (8-17)