Financial Institution:
Deposit Account Number:

DEPOSIT BROKER SUBMISSION CHECKLIST

BROKER NAME:	DTC BROKER NUMBER:
MAILING ADDRESS:

CONTACT PERSON:
Telephone Number:	Fax Number:
Email address:

SECONDARY PERSON:
Telephone Number:	Fax Number:
Email address:

DATA PROCESSING CONTACT:
Telephone Number:	Fax Number:
Email address:

SECONDARY PERSON:
Telephone Number:	Fax Number:
Email address:

DATA SUBMISSION:

We are submitting a file in the required format:	Yes	No

Please note that only data submitted in the prescribed format will be processed. Manual listings will not be accepted. Please label your diskette(s) or compact disc(s) with your firm’s name and DTC broker number, if applicable.

Number of Records on the file:
Principal Value:

NOTE: The principal value listed above should be the same as the data on the file. If the above stated data does not balance, the file will not be processed and your firm will lose its position in the processing sequence.

The undersigned affirms that all of the information submitted is correct and contains no material omissions and that to the best of his/her knowledge, the data submitted is a final, complete and accurate submission including information from ALL sub-brokers/agents, if any, with the exception of brokers (indicate number) in the amount of $ (total) which are included in the aggregate on the file. I understand that my firm will not be paid these sums until the sub-tier broker submits complete investor information and required documentation to the FDIC.

Prepared by:	Date:

FOR FDIC USE ONLY

BALANCE VERIFIED	DATA LOADED	DATA UNLOADED	DATA LOADED
LOAD CERTIFIED	DATA GROUPED	INFORMATION FAXED

January 2002

Financial Institution:

2004-10-27

Federal Deposit Insurance Corporation