Federal Deposit
Insurance Corporation

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

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Deposit Broker's Processing Guide
V. Affidavits and Declarations

Affidavits & Declarations Checklist

In order for the FDIC to process the insurance payment on your deposits at the closed institution, the following forms may be required. Failure to submit the required information and forms will delay the payment of your deposit. Copies of these forms are attached and can also be retrieved from the FDIC website: www.fdic.gov. Part I identifies the various affidavits and declarations that may be needed. Part II outlines the types of deposits and ownership capacities and the documentation required.

Part I

Affidavit of Agency Account 156kb (Word Help)
  • Required from every broker; i.e., first tier, second tier, etc.
  • Attach a copy of your standard form of agency agreement, OR
  • Attach other written documentation to support the agency relationship if no standard form of agency is used; i.e., account setup sheet.
  • Complete Exhibit A. A computer-generated customer ownership list may be substituted for Exhibit A, provided that all of the requested information for each customer is included.
  • Include account setup sheet on all deposits $250,000 or greater in the aggregate.
  • An officer authorized to sign on behalf of your firm must sign the Affidavit.
  • Medallion guarantee is acceptable in place of a notary signature.

Power of Attorney-Word 41k (Word Help)

  • Not a required document. Complete only if needed.
Declaration for Power of Attorney-Word 35k (Word Help)
  • Required only if submitting a Power of Attorney not utilizing FDIC’s form.
  • Attach a copy of the Power of Attorney document.
Declaration for Custodian Deposit-Word 41k (Word Help)
  • Required when the broker’s investor is acting as custodian for others and the account totals $250,000 or greater in the aggregate.
Declaration for Joint Ownership Deposit-Word 52k (Word Help)
  • Required for all joint ownership deposits $250,000 or greater, in the aggregate, when the account setup sheet is not provided.

Declaration for Testamentary Deposit-Word 63k (Word Help)

  • The above form is required for all testamentary deposits that are also known as payable on death (POD) accounts, revocable trusts and in trust for (ITF) accounts. Submit for all deposits $250,000 or greater in the aggregate.
Declaration for Revocable Trust-Word 69k (Word Help)
  • Required for all deposits in the name of a trust totaling $250,000 or greater in the aggregate.
Declaration for Irrevocable Trust 95 KB (Word Help)
  • Required for all deposits in the name of a trust totaling $250,000 or greater in the aggregate.

Declaration of Independent Activity-Word 51k (Word Help)
Declaration of Independent Activity for Unincorporated Association-Word 54k (Word Help)

  • Required of corporations, partnerships or unincorporated associations when the depositor states that the funds in two or more accounts are owned by separate entities. If this form is needed, the FDIC will make a request through the first-tier broker.
Declaration for Government Deposit-Word 52k (Word Help)
  • Required for all government deposits $250,000 or greater in the aggregate.
Declaration for IRA/KEOGH Deposit-Word 41k (Word Help)
  • For all IRA and KEOGH deposit accounts $250,000 or greater in the aggregate, the FDIC requires that the standard IRA agreement between the broker and the IRA owner be submitted. If there is not one, complete and submit this form.
Declarations for Employee Benefit Plan Deposits

Part II

In general, the following forms are required when a deposit totals $250,000 or greater in the aggregate.

Single Ownership Deposit
  • No affidavit or declaration required.
Custodian Account Joint Ownership Deposit Testamentary Deposit Irrevocable Trust or Revocable Living Trust Deposits Corporation, Partnership, or Unincorporated Association Deposit

Government Deposit (Public Unit)

IRA and Keogh Deposits Employee Benefit Plan Deposits
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Last Updated 7/3/2014 bdclaims@fdic.gov