142 - Voluntary Liquidation - Report of Condition at Com

OMB no. 1557-0014

Expiration date: See www.occ.gov

Voluntary Liquidation

Report of Condition at Commencement of 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

Report of condition at commencement of liquidation filed pursuant to 12 CFR 5.48(e)(4)

Liquidation start date:

Liquidation account outstanding balance (if applicable):

I, the undersigned, being the liquidating agent/correspondent, certify the attached report of assets and liabilities (for the most recent month end) to be a true statement, to the best of my knowledge and belief.

(Liquidating agent) (Correspondent for committee)

(Committee member)

(Committee member)

(Committee member)

(Committee member)

Signature date:

[A majority of the liquidating committee must sign this document.]

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