7200/27 Declaration for Trust Accounts

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

Federal Deposit Insurance Corporation

DECLARATION FOR TRUST ACCOUNT
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 request 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 may be furnished to third parties, including law enforcement authorities, as
authorized by law, or used according to any of the other routine uses described in the FDIC Financial
Institution Resolution and Receivership Records (FDIC-013) System of Records. A complete copy of
this System of Records is available at www.fdic.gov/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 60 minutes 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 unless it
displays a currently valid OMB control number.

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FDIC 7200/27 (9-23)

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

Federal Deposit Insurance Corporation

DECLARATION FOR TRUST ACCOUNT
INSTRUCTIONS: Submit completed forms electronically to [email protected] or by mail to the FDIC Claims
Department at 600 North Pearl Street, Suite 700, Dallas, TX 75201. (Include all supporting documentation.) For
expedited processing, complete the declaration using the Failed Bank Customer Service Center at https://
resolutions.fdic.gov/claimsportal/s/. Send questions to [email protected].
SECTION I - FINANCIAL INSTITUTION
1. Name of Failed Bank

2. Closing Date

SECTION II - TRUST ACCOUNT INFORMATION
3. Name of Trust
4. Account Number

5. Telephone Number

SECTION III - DECLARATION FOR TRUST ACCOUNT

6. The undersigned is (are) trustee(s) of the attached Trust (the "Trust") for which the above-referenced account(s) (the
"Account(s)") was/were established.
7. The names of all the trustee(s) of said Trust on the closing date were: (If you need more space, please attach a separate
sheet of paper.)
TRUSTEE(S) NAME
(First, Middle, Last, Generation or Entity Name)

LAST 4-DIGITS OF TAX ID
(SSN, ITIN, or EIN)

8. The grantor(s)/settlor(s) of the Trust are: (If you need more space, please attach a separate sheet of paper.)

GRANTOR(S)/SETTLOR(S) NAME
(First, Middle, Last, Generation
or Entity Name)

FDIC 7200/27 (9-23)

LAST 4-DIGITS OF
TAX ID
(SSN, ITIN, or EIN)

IS GRANTOR/
SETTLOR ALSO A
BENEFICIARY OF
THE TRUST?
Yes

No

N/A

IF GRANTOR/
SETTLOR IS
DECEASED, ENTER
DATE OF DEATH

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

9. List all beneficiaries of the Trust that receive cash assets under the trust: (If you need more space, please attach a
separate sheet of paper.)

BENEFICIARY(IES) NAME
(First, Middle, Last, Generation
or Entity Name)

LAST 4-DIGITS BENEFICIARY
OF TAX ID
TYPE
(SSN, ITIN, or
(Primary or
EIN)
Contingent)

IF CHARITY OR NONIF INDIVIDUAL, IS THE PROFIT, IS THE ENTITY
PERSON LIVING AT
ACTIVE AND
THE TIME OF BANK
RECOGNIZED BY THE
FAILURE?
IRS?
Yes
No
N/A
Yes
No
N/A

10. The undersigned, or any one of them, has (have) the authority under the Trust to execute, on behalf of the Trust,
this declaration and all other documents which the Federal Deposit Insurance Corporation may require to be
executed in connection with the payment of insurance on the Account(s) and to bind the attester by their action.
11. All copies of Trust documents have been submitted to the Federal Deposit Insurance Corporation with this
declaration.
12. This declaration is made to induce the Federal Deposit Insurance Corporation to pay insurance covering the
Account(s), to the extent the Account(s) is (are) covered by insurance.
13. This declaration, under penalty of perjury, is executed pursuant to 28 U.S.C. § 1746.
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).
I declare under penalty of perjury that the foregoing is true and correct.
I understand the Federal Deposit Insurance Corporation retains the right to collect any overpayment of deposit
insurance made to any depositor, including any overpayment made due to the existence of false or misleading
information provided to the Federal Deposit Insurance Corporation.
I understand that once I sign and submit this Declaration for Trust Account, I will no longer be able to make changes
to the submitted documents.

Attesting Individual Name (Please Print)

Attester Signature

Date Executed

Attesting Individual Name (Please Print)

Attester Signature

Date Executed

NOTE: Please attach a copy of the Trust and any additional supporting documents such as amendments or addendums and
certificate(s) of death. Please include only documents dated prior to or as of the failed bank closing date. Changes made to the Trust
or any amendment or addendum created after the closing date of the failed bank will not be considered as part of the insurance
determination.

FDIC 7200/27 (9-23)

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