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Federal Deposit
Insurance Corporation

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

Deposit Broker's Processing Guide

VII.  Affidavits and Declarations in Printable Format (Word and PDF)

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."

Forms in Printable Format (Word and PDF)

Title of Form Word Format PDF Format
Affidavit of Agency Account Word PDF
Declaration for Custodian Deposit Word PDF
Declaration for Defined Benefit Plan PDF
Declaration for Defined Contribution Plan Word PDF
Declaration for Health and Welfare Plan Word PDF
Declaration of Independent Activity Word PDF
Declaration of Independent Activity
for Unincorporated Association
Word PDF
Declaration for IRA/KEOGH Deposit Word PDF
Declaration for Joint Ownership Deposit Word PDF
Declaration for Plan and Trust Word PDF
Declaration for Government Deposit Word PDF
Declaration for Testamentary Deposit Word PDF
Declaration for Revocable Trust Word PDF
Declaration for Irrevocable Trust Word PDF
Deposit Broker Submission Checklist Word PDF
Declaration for Power of Attorney Word PDF

Instructions for Employee Benefit Plan Deposits  

Affidavits and Declarations Checklist

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