Voluntary Liquidation - Report of Condition at Commencem

Office of the Comptroller of the Currency
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):

1

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.]

2