Form 7200/06 Declaration of Independent Activity

OMB Number: 3064-0143
Expiration Date: 09/30/2023

Federal Deposit Insurance Corporation

DECLARATION OF INDEPENDENT ACTIVITY
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 you provide may be provided to appropriate Federal, state, local or foreign law
enforcement authorities; to a court, administrative tribunal, or a party in litigation; to contractors, agents and other third parties as
authorized by law, and in accordance with 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. 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 1/2 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 17th 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.

NOTE: 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).
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FDIC 7200/06 (11-21)

OMB Number: 3064-0143
Expiration Date: 09/30/2023

Federal Deposit Insurance Corporation

DECLARATION OF INDEPENDENT ACTIVITY
INSTRUCTIONS: When receiving deposit insurance, this form identifies owner(s) of the funds on deposit and seeks confirmation that
similarly titled accounts are independent businesses entitled to separate deposit insurance. The Federal Deposit Insurance
Corporation completes Section I - Financial Institution; and the Depositor/Representative completes Sections II - Declaration. The
Depositor ID is provided by the Federal Deposit Insurance Corporation FDIC. Select "Email Form" button to submit completed form,
supporting documents, and required attachments to [email protected] or mail form and all supporting documents to the
Claims Department at 600 North Pearl Street, Suite 700, Dallas, TX 75201. For questions, contact Depositor Claims Agent at
972-761-2112.
SECTION I - FINANCIAL INSTITUTION
1. Name

2. Closing Date

3. Account Number

4. Depositor ID

SECTION II - DECLARATION
5. The undersigned is
(Title)
(the "Accountholder") and is responsible for:
Describe Duties

6. The Accountholder is engaged in the business of:

7. The source of funds for the above-listed Account was:

FDIC 7200/06 (11-21)

of
(Name of Organization)

OMB Number: 3064-0143
Expiration Date: 09/30/2023

8. The major stockholders (if the Accountholder is a corporation) or partners (if the Accountholder is a partnership) of the
Accountholder and their percentage ownership interest were the following on the closing date:

9. The officers and directors of the Accountholder on the closing date were the following:

10. Attach the following when you select the "Email Form" button at the top right hand corner of form:
a. A copy of the certificate of good standing from the Secretary of State of incorporation dated no earlier than one year prior to
the closing date or the certificate of partnership filed with the proper governmental authority; and
b. A copy of the Articles of Incorporation or Partnership Agreement (whichever is applicable) for the Accountholder; and
c. The most recent separate income tax return filed with the Internal Revenue Service or the most recent financial statements.

11. Does the Accountholder have an ownership interest, directly or indirectly, in any other accounts at the closed institution?
Yes

No

If Yes, provide Account Number:

12. The undersigned, or any one of them has (have) been authorized to execute and deliver to the Federal Deposit Insurance
Corporation (“FDIC”) information concerning the above-referenced Account at the closed institution and to take any and all other
actions and to execute any and all other documents in connection with the payment of insurance on such Account and to
subrogate to the FDIC the Accountholder's rights in said Account to the extent such Account is insured. If not applicable, please
select box.
Not Applicable
13. The declaration is made to induce the FDIC to pay insurance covering the Account to the extent that the Account is covered by
insurance.
14. This declaration, under penalty of perjury, is executed pursuant to 28 U.S.C. § 1746.

I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct.
Executed on:

(Signature)

(Print Name)

FDIC 7200/06 (11-21)