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Federal Deposit
Insurance Corporation

Each depositor insured to at least $250,000 per insured bank

Failed Bank Information

Instructions for Depositors

If you have an account or group of accounts at the failed bank that exceeds $250,000 you may need to complete certain declarations or affidavits and provide documentation so that the FDIC can make an insurance determination on your account(s). To expedite the handling of your accounts you may wish to complete these documents before calling the FDIC.

If your deposits DO NOT exceed $250,000 you DO NOT need to complete these documents and you DO NOT need to contact the FDIC. If you placed your accounts directly with the failed institution and they are held in an IRA account, a business account, a single ownership account (and you have no trust accounts) or a joint account you DO NOT need to complete any of these forms.

If you submit documents directly to the FDIC please write your Name and Account Number on all documents in the event a document gets separated. Also include your phone number and the best time to call. Your Customer Number can be found on the correspondence sent to you; if you do not have your Customer Number, leave the field blank. For each declaration or form there is an example of a completed declaration or form in these instructions.

If you are an investor with a deposit broker, you may need to complete one of these forms only if your investment exceeds $250,000. However, you must mail your form to your deposit broker for submission to the FDIC.

Forms that can be completed on line can be accessed at the FDIC website. Please return the forms to the FDIC by FAX (facsimile) or mail at the number or address listed for the failed institution.

  1. Instructions for completing the Declaration for Testamentary Deposit (In Trust For (ITF) or Payable on Death (POD) Accounts)
  2. Instructions for completing the Declaration for Revocable Trust (Formal Revocable Trust Agreements)
  3. Instructions for completing the Declaration for Irrevocable Trust (Irrevocable Trust Agreements)
  4. Instructions for Employee Benefit Plan Administrators
  5. Instructions for completing the Declaration for Plan and Trust form
  6. Instructions for completing the Declaration for Defined Contribution Plan form
  7. Instructions for completing the Declaration for Defined Benefit Plan form
  8. Instructions for completing the Declaration for Health and Welfare Plan form
  9. Instructions for completing the Declaration for Custodian Deposit form
  10. Instructions for completing the Declaration for Government Deposit form
  11. Instructions for completing the Declaration of Independent Activity form
  12. Instructions for completing the Declaration of Independent Activity for Unincorporated Association form
  13. Instructions for completing the Declaration for Joint Ownership Deposit form
  14. Instructions for completing the Declaration for IRA/KEOGH Deposit form
  15. Instructions for completing the Declaration for Power of Attorney form
  16. Instructions for completing the Power of Attorney form
  17. Instructions for completing the Affidavit of Agency Account form
  1. Instructions for completing the Declaration for Testamentary Deposit (In Trust For (ITF) or Payable on Death (POD) Accounts)

    If you had a deposit at the failed institution which was held in trust ITF (in trust for) or POD (payable on death) for one or more beneficiaries (without a written trust agreement) and the total amount of the deposit exceeds $250,000 per depositor, additional documentation may be required in order for the FDIC to complete its insurance determination on your accounts.

    Example: Jane Jones ITF Mary Johnson and Jack Jones $300,000

    Please complete the Declaration for Testamentary Deposit

    Instructions

    For every declaration the Name of the Closed Financial Institution (Failed Bank) is inserted on the line that says Financial Institution. The date the institution closed is inserted on the line that says Closing Date.

    This form should be completed when the account is a POD or ITF (no written trust agreement) and there is one or more grantors.

    To be completed:

    1. Account Number - If there are multiple accounts, indicate all account numbers for this ownership category.
    2. Customer Number - If known
    3. Name of grantor(s) - If the grantor is deceased indicate in this area, with the date of death.
    4. Percentage of Funds Contributed to This Account - indicate the percentage of ownership in the accounts for each grantor.
    5. Name of Beneficiary - If the beneficiary is an individual indicate the name of each beneficiary, and whether the person is living. If the beneficiary is a charity or non-profit indicate whether it is recognized by the IRS.
    6. Signature of Grantor and date of execution of declaration.

    Please complete the declaration and return it to the FDIC by FAX (facsimile) or mail to the number or address listed for the failed institution.

    Once the FDIC receives your documentation and makes its determination you will be notified of the determination. Because of the volume of determinations similar to yours, it may take several weeks to process your determination. However, your funds have been transferred to the Acquiring Institution, or in the case of a pay out, to the FDIC, and are on hold until a determination is made.

    Example of completed Declaration for Testamentary Deposit (pdf help)

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  2. Instructions for completing the Declaration for Revocable Trust (Formal Revocable Trust Agreements)

    If you had a deposit at the failed institution which was held in trust under a written revocable (formal) trust agreement for one or more beneficiaries and the total amount of the deposit exceeds $250,000 per depositor, additional documentation may be required in order for the FDIC to complete its insurance determination on your accounts.

    Example: Doe Family Trust, Mary Doe, Trustee, John Doe, Trustee $750,000

    Please complete the Declaration for Revocable Trust.

    Instructions

    For every declaration the Name of the Closed Financial Institution (Failed Bank) is inserted on the line that says Financial Institution. The date the institution closed is inserted on the line that says Closing Date.

    This form should be completed when the depositor has a written trust agreement, such as a Family Trust, Living Trust.

    To be completed:

    1. Account Number - If there are multiple accounts, indicate all account numbers for this ownership category.
    2. Customer Number - If known
    3. Indicate the names of the trustees - quite often the trustee(s) may not be the grantors (or owners of the trust).
    4. Indicate the names of the settlor(s)/grantor(s) (A) and (B) of the trust, and his/her percentage of contributions (funds) to the trust.
    5. If a grantor is deceased, indicate in this area with the date of death.
    6. Indicate the name(s) of all beneficiaries on the account and beneficiary type (individual/Charity/ Non-Profit).
    7. If the beneficiary is an individual indicate whether the person is living. If the beneficiary is a charity or non-profit indicate whether it is recognized by the IRS.
    8. Signature of Trustee(s) and date of execution of declaration.

    Please complete the declaration and, along with a complete copy of the trust agreement, return it to the FDIC by FAX (facsimile) or mail at the number or address listed for the failed institution

    Once the FDIC receives your documentation and makes its determination you will be notified of the determination. Because of the volume of determinations similar to yours, it may take several weeks to process your determination. However, your funds have been transferred to the Acquiring Institution, or in the case of a pay out, to the FDIC, and are on hold until a determination is made.

    Example of completed Declaration for Revocable Trust (Revocable) (pdf help)

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  3. Instructions for completing the Declaration for Irrevocable Trust (Formal Irrevocable Trust Agreements)

    If you had a deposit at the failed institution which was held in trust under a written irrevocable (formal) trust agreement for one or more beneficiaries and the total amount of the deposit exceeds $250,000 per depositor, additional documentation may be required in order for the FDIC to complete its insurance determination on your accounts.

    Example: Doe Family Irrevocable Trust, John Doe, Trustee, Mary Doe, Trustee $275,000

    Please complete the Declaration for Irrevocable Trust.

    Instructions

    This form should be completed when the depositor has a written irrevocable trust agreement.

    1. Account Number - If there are multiple accounts, indicate all account numbers for this ownership category.
    2. Customer Number - If known
    3. Indicate the names of the trustees - quite often the trustee(s) may not be the grantors (or owners of the trust).
    4. Indicate the names of the settlor(s)/grantor(s) (A) and (B) of the trust, and his/her percentage of contributions (funds) to the trust.
    5. If a grantor is deceased, indicate in this area with the date of death.
    6. Indicate the name(s) of all beneficiaries on the account.
    7. If the beneficiary is an individual Indicate whether the person is living.
    8. Signature of Trustee(s) and date of execution of declaration.

    Please complete the declaration and, along with a complete copy of the trust agreement, return it to the FDIC by FAX (facsimile) or mail at the number or address listed for the failed institution

    Once the FDIC receives your documentation and makes its determination you will be notified of the determination. Because of the volume of determinations similar to yours, it may take several weeks to process your determination. However, your funds have been transferred to the Acquiring Institution, or in the case of a pay out, to the FDIC, and are on hold until a determination is made.

    Example of completed Declaration for Irrevocable Trust (Irrevocable) (pdf help)

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  4. Instructions for Employee Benefit Plan Administrators

    If you are the administrator of an Employee Benefit Plan account, including a Defined Benefit Plan, Defined Contribution Plan or Health and Welfare Plan, and the amount of the deposit(s) exceeds $250,000 additional documentation will be required for the FDIC to complete its insurance determination.

    The following instructions are applicable to all three Employee Benefit Plans mentioned above. Improper completion of these forms may delay the processing of your insurance determination

    Instructions

    For every declaration the Name of the Closed Financial Institution (Failed Bank) is inserted on the line that says Financial Institution. The date the institution closed is inserted on the line that says Closing Date.

    Employee Benefit Plan Deposits

    If an employee benefit plan deposit exceeds $250,000 in the aggregate, before an insurance determination can be made on the benefit plan deposit, an executed copy of the Declaration for Plan and Trust must be submitted along with a copy of:

    1. The pages of the Trust appointing the trustees and showing the trustees' signatures, and
    2. Any one of:
      1. The Plan,
      2. The adoption agreement, or
      3. The IRS determination letter for the Plan.

    If the Plan and Trust are part of the same document, one copy of the complete document may be provided.

    If the trustees named in the Trust are not the current trustees, please also attach to the Declaration for Plan and Trust the resolution appointing the current trustees.

    If there is only one participant in the Plan, please indicate this on the Declaration for Plan and Trust. If there is more than one participant in the Plan, the following information must also be submitted:

    1. If the Plan is a Defined Contribution Plan, please complete the Declaration for Defined Contribution Plan.
    2. If the Plan is a Defined Benefit Plan, please have the Declaration for Defined Benefit Plan completed. A certified actuary must complete the Declaration for Defined Benefit Plan.

      Questions 5 and 6 of the Declaration for Defined Benefit Plan must be answered if any of the following are applicable:

      1. The account had more than $252,000 in it on the closing date;
      2. There are other accounts for an employee benefit plan with the same sponsor at the defaulted institution; or
      3. The present value of any one participant's accrued benefit (including rollover, other voluntary participant contributions, and any other amounts held for the benefit of the participant) exceeds 95% of the total Plan assets on the closing date.
    3. If the Plan is a Health or Welfare Plan (medical, dental, life insurance, etc., benefits), please complete the Declaration for Health and Welfare Plan

    FAILURE TO PROVIDE ALL OF THE INFORMATION REQUESTED WILL DELAY THE PAYMENT OF INSURANCE ON YOUR ACCOUNT.

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  5. Instructions for completing the Declaration for Plan and Trust form

    For every declaration the Name of the Closed Financial Institution (Failed Bank) is inserted on the line that says Financial Institution. The date the institution closed is inserted on the line that says Closing Date.

    The Declaration for Plan and Trust form should be completed by an administrator of employee benefit plan accounts which hold funds for participants in Defined Benefit, Defined Contribution or Health and Welfare Plans.

    If there is only one participant in the Plan, please indicate this on the Declaration for Plan and Trust. If there is more than one participant in the Plan, the following information must also be submitted:

    1. If the Plan is a Defined Contribution Plan, please complete the Declaration for Defined Contribution Plan
    2. If the Plan is a Defined Benefit Plan, please have the Declaration for Defined Benefit Plan completed. A certified actuary must complete the Declaration for Defined Benefit Plan.

      Questions 5 and 6 of the Declaration for Defined Benefit Plan must be answered if any of the following are applicable:

      1. The account had more than $252,000 in it on the closing date;
      2. There are other accounts for an employee benefit plan with the same sponsor at the defaulted institution; or
      3. The present value of any one participant's accrued benefit (including rollover, other voluntary participant contributions, and any other amounts held for the benefit of the participant) exceeds 95% of the total Plan assets on the closing date.
    3. If the Plan is a Health or Welfare Plan (medical, dental, life insurance, etc., benefits), please complete the Declaration for Health and Welfare Plan

    FAILURE TO PROVIDE ALL OF THE INFORMATION REQUESTED WILL DELAY THE PAYMENT OF INSURANCE ON YOUR ACCOUNT

    The Declaration for Plan and Trust should be completed by an administrator of employee benefit plan accounts which hold funds for participants in Defined Benefit, Defined Contribution or Health and Welfare Plans.

    To be completed:

    1. Account Number - If there are multiple accounts, indicate all account numbers for this ownership category.
    2. Customer Number - If known
    3. Reenter the account number of the Plan and Trust.
    4. Enter the name of the failed Financial Institution.
    5. Indicate the names of the Trustees of the Plan. Insert the name of the specific plan.
    6. Check the proper box to indicate the number of participants in the plan.
    7. Indicate whether the Trustee(s) does not have authority to execute this document on behalf of the Plan and Trust by checking the "Not Applicable" box, if applicable.
    8. Signature of Trustee and date of execution of declaration.

    Example of completed Declaration for Plan and Trust (pdf help)

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  6. Instructions for completing the Declaration for Defined Contribution form.

    For every declaration the Name of the Closed Financial Institution (Failed Bank) is inserted on the line that says Financial Institution. The date the institution closed is inserted on the line that says Closing Date.

    Example: John Roberts, MD, Professional Association 401K plan $430,000

    The Declaration for Defined Contribution form should be completed by the actuary of a Defined Benefit Plan.

    To be completed:

    1. Account Number - If there are multiple accounts, indicate all account numbers for this ownership category.
    2. Customer Number - If known
    3. Indicate the name of the Defined Contribution Plan.
    4. Include the account number for the funds of the Defined Contribution Plan.
    5. Include the name of the closed Financial Institution.
    6. Indicate the total number of participants as of the closing date.
    7. Indicate whether the employer made contributions to the Plan between the date of the latest report and the closing date by checking the appropriate box.
    8. Indicate whether a participant made contributions to the Plan between the date of the report and the date noted on the declaration by checking the appropriate box.
    9. Indicate whether distributions of Plan assets were made between the date of the report and the closing date and check the appropriate box.
    10. Indicate whether the participant has elected to direct his/her account balance by checking the appropriate box.
    11. Indicate whether any significant event has occurred with regard to the Plan by checking the appropriate box.
    12. Indicate whether the account is an investment of general plan assets or is self-directed by checking the appropriate box.
    13. Signature of Trustee(s) and date of execution of declaration.

    Example of completed Declaration for Defined Contribution (pdf help)

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  7. Instructions for completing the Declaration for Defined Benefit Plan form.

    For every declaration the Name of the Closed Financial Institution (Failed Bank) is inserted on the line that says Financial Institution. The date the institution closed is inserted on the line that says Closing Date.

    If you are the administrator of a Defined Benefit Plan and the amount of the deposit exceeds $252,000 you will be required to complete the Declaration for Plan and Trust and the Declaration for Defined Benefit Plan.

    Example: Dr. John James, & Associates, Inc. Defined Benefit Pension Plan $290,000

    The Declaration for Defined Benefit Plan form should be completed by the actuary of a Defined Benefit Plan.

    To be completed:

    1. Account Number - If there are multiple accounts, indicate all account numbers for this ownership category.
    2. Customer Number - If known
    3. Indicate the name of the Defined Benefit Plan.
    4. Include the account number for funds of the Defined Benefit Plan.
    5. Include the name of the closed Financial Institution.
    6. Indicate the total number of participants as of the closing date.
    7. Indicate whether the aggregate balance was below $252,000 on the closing date, and whether a single participant's total interest exceeded 95% of total Plan assets by checking the appropriate box.
    8. Indicate the largest percentage of Plan assets owned by any participant as of the date of closing and include the participant's name.
    9. Include a percentage range of participants' accrued benefits relative to the Plan assets.
    10. Indicate whether the account is an investment of general plan assets or is self-directed by checking the appropriate box.
    11. Signature of Actuary and date of execution of declaration.

    Example of completed Declaration for Defined Benefit Plan (pdf help)

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  8. Instructions for completing the Declaration for Health and Welfare Plan form

    For every declaration the Name of the Closed Financial Institution (Failed Bank) is inserted on the line that says Financial Institution. The date the institution closed is inserted on the line that says Closing Date.

    If you are the administrator of a Health and Welfare Plan and the amount of the deposit exceeds $250,000 you will be required to complete the Declaration for Plan and Trust and the Declaration for Health and Welfare Plan.

    Example: International Workers Union Health and Welfare Plan $350,000

    The Declaration for Heath and Welfare Plan form should be completed by an administrator of a Health and Welfare Plan.

    To be completed:

    1. Account Number - If there are multiple accounts, indicate all account numbers for this ownership category.
    2. Customer Number - If known
    3. Indicate the capacity in which the undersigned, person completing the declaration, is acting, i.e., owner or administrator.
    4. Indicate the name of the Health and Welfare Plan for which the account was established.
    5. Indicate the total number of participants in the plan as of the date of closing of the Financial Institution.
    6. Indicate the value of Plan assets as of the closing date.
    7. Indicate whether death benefits were paid from the assets of the Plan by checking the appropriate box.
    8. Indicate whether claims for benefits were submitted, but had not been paid as of the closing date by checking the appropriate box.
    9. Signature of Trustee and date of execution of declaration.

    Example of completed Declaration for Health and Welfare Plan (pdf help)

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  9. Instructions for completing the Declaration for Custodian Deposit form

    For every declaration the Name of the Closed Financial Institution (Failed Bank) is inserted on the line that says Financial Institution. The date the institution closed is inserted on the line that says Closing Date.

    The Declaration for Custodian Deposit form should be completed when an account has an assigned Custodian who acts on the behalf of the Principal or legal owner of the account.

    To be completed:

    1. Account Number - If there are multiple accounts, indicate all account numbers for this ownership category.
    2. Customer Number - If known
    3. Indicate the name of the Principal.
    4. Indicate the relationship of the Custodian and Principal of the account.
    5. Note any additional accounts at the Closed Financial Institution (Failed Bank) held by the Principal, whether established by the Principal or set up on his/her behalf.
    6. Signature of Custodian and date of execution of declaration.

    Example of completed Declaration for Custodian Deposit (pdf help)

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  10. Instructions for completing the Declaration for Government Deposit form

    For every declaration the Name of the Closed Financial Institution (Failed Bank) is inserted on the line that says Financial Institution. The date the institution closed is inserted on the line that says Closing Date.

    The Declaration for Government Deposit form should be completed by the official custodian or authorized signor of deposits of a governmental entity or public unit.

    To be completed:

    1. Account Number - If there are multiple accounts, indicate all account numbers for this ownership category.
    2. Customer Number - If known
    3. Include name of the Governmental Entity or Public Unit which owns the account.
    4. Indicate the type of Governmental Entity or Public Unit that owned the deposit by checking the appropriate box.
    5. Indicate additional accounts where the Governmental Entity or Public Unit has ownership interest at the closed Financial Institution.
    6. Signature of Official Custodian(s) and date of execution of declaration.

    Example of completed Declaration for Government Deposit (pdf help)

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  11. Instructions for completing the Declaration of Independent Activity form

    For every declaration the Name of the Closed Financial Institution (Failed Bank) is inserted on the line that says Financial Institution. The date the institution closed is inserted on the line that says Closing Date.

    The Declaration of Independent Activity form should be completed by an authorized individual of the organization, business, or company who is the accountholder.

    To be completed:

    1. Account Number - If there are multiple accounts, indicate all account numbers for this ownership category.
    2. Customer Number - If known
    3. Indicate the official title of the individual completing the form.
    4. Indicate the Name of the Organization which owns the account.
    5. Describe the duties and responsibilities performed by undersigned.
    6. Describe the type of business the accountholder is engaged in.
    7. Indicate the source of funds held in the account.
    8. Indicate the major stockholders or owners of the organization (accountholder) as of the closing date.
    9. Indicate the officers and directors of the accountholder as of the closing date.
    10. Indicate whether the undersigned does not have the authority to execute and deliver information in connection with the deposit insurance determination on this account by checking the "Not Applicable" box.
    11. Sign and date the execution of declaration.

    Example of completed Declaration of Independent Activity (pdf help)

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  12. Instructions for completing the Declaration of Independent Activity for Unincorporated Association form

    For every declaration the Name of the Closed Financial Institution (Failed Bank) is inserted on the line that says Financial Institution. The date the institution closed is inserted on the line that says Closing Date.

    The Declaration of Independent Activity for Unincorporated Association form should be completed by an authorized individual of the unincorporated association who is the accountholder.

    To be completed:

    1. Account Number - If there are multiple accounts, indicate all account numbers for this ownership category.
    2. Customer Number - If known
    3. Indicate the official title of the individual completing the form.
    4. Indicate the Name of the Organization which owns the account.
    5. Describe the duties and responsibilities performed by the undersigned.
    6. Describe the purpose of the accountholder. Purposes of unincorporated associations include religious, educational, charitable or other noncommercial purposes.
    7. Indicate the source of funds held in the account.
    8. Indicate the number of members of the accountholder.
    9. Indicate the officers of the accountholder.
    10. Indicate whether the undersigned does not have the authority to execute and deliver information in connection with deposit insurance determination on this account by checking the "Not Applicable" box.
    11. Sign and date the execution of declaration.

    Example of completed Declaration of Independent Activity for Unincorporated Association (pdf help)

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  13. Instructions for completing the Declaration for Joint Ownership Deposit form

    For every declaration the Name of the Closed Financial Institution (Failed Bank) is inserted on the line that says Financial Institution. The date the institution closed is inserted on the line that says Closing Date.

    The Declaration for Joint Ownership Deposit form should be completed by all co-owners of the account.

    To be completed:

    1. Account Number - If there are multiple accounts, indicate all account numbers for this ownership category.
    2. Customer Number - If known
    3. Indicate the names of the owners of the funds held jointly at the closed Financial Institution.
    4. (A) Name of 1st owner and percentage of funds contributed to the account
      (B) Name of 2nd owner and percentage of funds contributed to the account. Continue until all owners of funds have been disclosed.
    5. If an owner is deceased, indicate in this area with the date of death.
    6. Indicate if the funds in the account were placed by a trustee under a written trust agreement by checking the appropriate box.
    7. Signature of each owner and date of execution of declaration.

    Example of completed Declaration for Joint Ownership Deposit (pdf help)

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  14. Instructions for completing the Declaration for IRA/KEOGH Deposit form

    For every declaration the Name of the Closed Financial Institution (Failed Bank) is inserted on the line that says Financial Institution. The date the institution closed is inserted on the line that says Closing Date.

    The Declaration for IRA/KEOGH Deposit form should be completed for deposits which consist of funds held for individual retirement accounts, eligible deferred compensation plans and other self-directed retirement plans.

    To be completed:

    1. Account Number If there are multiple accounts, indicate all account numbers for this ownership category.
    2. Customer Number - If known
    3. Indicate the type of retirement plan the deposit was held for by checking the appropriate box.
    4. Indicate the name of the trustee or administrator of the retirement plan. This may be the name of a person or a financial institution.
    5. Indicate the capacity in which the undersigned is employed.
    6. Indicate the name of the owner of the account.
    7. Signature of Trustee or Administrator and date of execution of declaration.

    Example of completed Declaration for IRA/KEOGH Deposit (pdf help)

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  15. Instructions for completing the Declaration for Power of Attorney form

    For every declaration the Name of the Closed Financial Institution (Failed Bank) is inserted on the line that says Financial Institution. The date the institution closed is inserted on the line that says Closing Date.

    The Declaration for Power of Attorney form should be completed by an individual who has legal authority as Power of Attorney and is acting on behalf of a Principal or owner of deposits.

    To be completed:

    1. Account Number - If there are multiple accounts, indicate all account numbers for this ownership category.
    2. Customer Number - If known
    3. Indicate the name of the person appointed to act as attorney-in-fact.
    4. Indicate the name of the Principal or the person for whom Power of Attorney has been given.
    5. Signature of Attorney-in-Fact and date of execution of declaration.

    Example of completed Declaration for Power of Attorney (pdf help)

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  16. Instructions for completing the Power of Attorney form

    For every declaration the Name of the Closed Financial Institution (Failed Bank) is inserted on the line that says Financial Institution. The date the institution closed is inserted on the line that says Closing Date.

    The Power of Attorney form is used to appoint an individual as agent and attorney to act on behalf of the accountholder to make proof of claims on insured deposits.

    To be completed:

    1. Account Number - If there are multiple accounts, indicate all account numbers for this ownership category.
    2. Customer Number - If known
    3. County of: Enter the county in which Notary of Public is legally recognized.
    4. State of: Enter the state in which Notary of Public is legally recognized.
    5. Indicate the name of the person appointed to have Power of Attorney, the company the appointee works for (if applicable) and name of the closed Financial Institution.
    6. Signature and address of Accountholder and date the document was notarized.

    Example of completed Power of Attorney (pdf help)

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  17. Instructions for completing the Affidavit of Agency Account form

    For every declaration the Name of the Closed Financial Institution (Failed Bank) is inserted on the line that says Financial Institution. The date the institution closed is inserted on the line that says Closing Date.

    The Affidavit of Agency Account form should be completed by persons or entities acting as agent (deposit brokers) for principals of deposits held for investment with the failed institution.

    1. Financial Institution Indicate the name of the closed Financial Institution.
    2. Closing Date Indicate the day the Financial Institution was closed by its chartering authority.
    3. Account Number or Cusip Number If there are multiple accounts, indicate all account numbers for this ownership category.
    4. Customer Number - If known
    5. State of: Enter the state in which Notary Public is legally recognized.
    6. County of: Enter the county in which Notary Public is legally recognized.
    7. Indicate the Title of the person completing the affidavit and the Name of the Organization for which he/she works.
    8. Indicate the closing date, name and address of the closed Financial Institution.
    9. Complete declaration of perjury for the officer and secretary.
    10. Document requires an authorized Notary.
    11. Indicate the agent's or firm's (broker's) tax identification number.
    12. Complete Exhibit A of affidavit, including account number, investor name and address, tax id number and principal amount.

    Example of completed Affidavit of Agency Account (pdf help)

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