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Deposit Broker's Processing Guide
V. Affidavits and Declarations
In order for the Federal Deposit Insurance Corporation to pay insurance on your accounts at the failed institution, the following Affidavits and Declarations must be completed, as applicable.  Descriptions of the Affidavits and Declarations are provided under the Affidavits and Declarations Checklist to enable you to determine whether a particular form is required in your situation.  Generally, an affidavit and/or declaration is required when an investor's deposits total or exceed $250,000 in the aggregate.

Paperwork Reduction Act. OMB No. 3064-0143. The information provided in this collection allows the FDIC to analyze ownership interest and provide deposit insurance coverage in situations where deposit brokers place deposits in an insured institution that subsequently fails. Deposit brokers must provide this information for the FDIC to pay deposit insurance. The FDIC 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 number. The estimated burden for this information collection is 70 responses and 140 hours per year. Comments about the accuracy of this burden estimate or suggestions about reducing the burden should be sent to Federal Deposit Insurance Corporation, 550 17th Street N.W., Washington, D.C. 20429, marked "Attention, Paperwork Reduction Act, Collection 3064-0143."

Affidavit of Agency Account-Word 166k (Word Help)
Power of Attorney-Word 41k (Word Help)
Declaration for Power of Attorney 35k (Word Help)
Declaration for Custodian Deposit 46 KB (Word Help)
Declaration for Joint Ownership Deposit 58 KB (Word Help)
Declaration for Testamentary Deposit 82 KB (Word Help)
Declaration for Revocable Trust 95 KB (Word Help)
Declaration for Irrevocable Trust 95 KB (Word Help)
Declaration of Independent Activity 60 KB (Word Help)
Declaration of Independent Activity for Unincorporated Association 62 KB (Word Help)
Declaration for Government Deposit 54 KB (Word Help)
Declaration for IRA/KEOGH Deposit 48 KB (Word Help)
Instructions for Employee Benefit Plan Deposits  
Declaration for Plan and Trust-Word 50 K (Word Help)
Declaration for Defined Benefit Plan-Word 51 KB (Word Help)
Declaration for Defined Contribution Plan-Word 60 KB (Word Help)
Declaration for Health and Welfare Plan-Word 46.5 KB (Word Help)
Affidavits and Declarations Checklist  
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Last Updated 01/13/2012 bdclaims@fdic.gov