Form 7200/09 Declaration for Testamentary Deposit (In Trust For or Pa

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

Federal Deposit Insurance Corporation

DECLARATION FOR TESTAMENTARY DEPOSIT

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 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. Any 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 7200/09 (11-21)

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

Federal Deposit Insurance Corporation

DECLARATION FOR TESTAMENTARY DEPOSIT
INSTRUCTIONS: The Federal Deposit Insurance Corporation completes Section I of this form, and the Depositor/Representative
completes Section II. The Depositor ID is provided by the Federal Deposit Insurance Corporation. Select "Email Form" button to
submit the completed form, supporting documents, and required documents 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 (are) Grantor(s) of the above account (the “Account”) and constitute all of the persons who own all of the funds
in the Account:
Name of Grantor(s)

Percentage of Funds Contributed To This Account

NOTE: Percentages must equal 100%
Complete the following if any grantor(s) are deceased:
Name of Grantor(s)

Date of Death

NOTE: The information above (percentage of funds contributed by each co-owner) may or may not be used by the FDIC in calculating
the insurance coverage of the Account. In the case of qualifying joint accounts held as tenants in common, the interests of the coowners are deemed equal unless otherwise stated in the depository institution's deposit account records.
12 C.F.R. § 330.10(f).
6. I (We) further declare that my (our) intent in establishing the Account was to provide that the funds in the Account, upon my (our)
death would be owned by the beneficiaries identified below.
7. The beneficiaries of the Account are as follows:
If Individual, Is The Person
Living?
Beneficiary

FDIC 7200/09 (11-21)

Beneficiary Type

Yes

No

If Charity or Non-Profit, Is It
Recognized By The IRS?
Yes

No

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

8. If the funds in this Account were placed by you as grantors under a written trust agreement, other than the account signature card,
attach a true, exact and complete copy of the trust agreement as in effect on the closing date. Select the "Email Form" button at
the top right hand corner of form to attach trust agreement to email.
NOTE: Be sure to attach this Declaration to the copy of the Trust agreement.
9. This declaration is made to induce the Federal Deposit Insurance Corporation to pay insurance covering the Account to the extent
that the Account is covered by insurance.
10. This declaration, under penalty of perjury, is executed pursuant to 28 U.S.C. § 1746.
I declare under penalty of perjury that the foregoing is true and correct. Executed on:

FDIC 7200/09 (11-21)

.

(Grantor Name)

(Grantor Signature)

(Grantor Name)

(Grantor Signature)