Form 7200/13 Declaration for Custodian Deposit

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

Federal Deposit Insurance Corporation

DECLARATION FOR CUSTODIAN 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.
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FDIC 7200/13 (7-21)

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

Federal Deposit Insurance Corporation

DECLARATION FOR CUSTODIAN 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 (FDIC). Select "Email Form" to
submit the 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 acting as custodian (the “Custodian”) for
who is my      

(the “Principal”),

. The Principal is the owner of all the funds in the above-referenced account

(the “Account”).

6. The undersigned's authority to serve as custodian for the Principal is derived from the attached written agreement(s). If no such
agreement is attached, please provide an explanation of the undersigned's authority to serve as Custodian for the Principal.

7. To the best knowledge of the undersigned, the Principal does not have an ownership interest in any other accounts at the above
institution, whether established by the Principal or by any other agent or custodian acting for the Principal, except as noted
here

.

8. 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.
9. 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:

(Custodian Name)

.

(Custodian Signature)

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).

FDIC 7200/13 (11-21)