Skip Header

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

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.  Generally, an affidavit and/or declaration is required when an investor's deposits total or exceed $250,000 in the aggregate.

Affidavit of Agency Account

The Affidavit of Agency Account (PDF | Word) is required from every broker (including ALL sub-tier brokers) and also requires two (2) attachments i.e., an Exhibit A and Exhibit B. Below are the specifics for all three:

Affidavit of Agency Account

  • 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. Include account setup sheet on all deposits $250,000 or greater in the aggregate.
  • The second page requires two (2) notarized signatures.
    • The first signer is generally an officer who is knowledgeable about all facts disclosed or addressed in the Affidavit and affirms that all statements are correct and the information contains no omissions.
    • The second is the Secretary or Assistant Secretary who certifies that the undersigned has the authority to execute the Affidavit and other documents on behalf of the Agent.
    • The signatures are then notarized. In place of a Notary, a Medallion Signature Guarantee stamp may be used.
    • The firm?s tax identification number must also be included on this form.

Exhibit A (page 3 of the Affidavit of Agency Account form)

  • Represents the customer ownership list and their interest (principal only) in the accounts as of the institution?s failure.
  • You may also reference that the ownership information is included on the enclosed electronic format.

Exhibit B (discussed in Paragraph 3 of the Affidavit of Agency Account form)

  • These documents are provided solely by the Agent/firm and would represent their standard new account agreements executed by the firm and the deposit owner.
  • Often there are separate documents for each type of account i.e., IRA, trust etc. The collection of all the agreements can be provided to cover all account types on deposit at the failed institution.
  • If specific owner/account information is needed to determine the amount of deposit insurance on a particular account, you will subsequently be contacted.
Declaration for Power of Attorney

The Declaration for Power of Attorney (Word) is required only if submitting a Power of Attorney not utilizing FDIC?s form.

Additional Forms by Type of Deposit and Ownership Capacity
Types of Deposits and Ownership Capacities FDIC Forms Documentation Requirements
Single Ownership Deposit N/A
  • No affidavit or declaration required.
Custodian Account

Declaration for Custodian Deposit
Word

  • Required when the broker?s?investor?is acting as custodian for others and the account totals $250,000 or greater in the aggregate.
Joint Ownership Deposit

Declaration for Joint Ownership Deposit
Word

  • Required for all joint ownership deposits $250,000 or greater, in the aggregate, when the account setup sheet is not provided.
Testamentary Deposit

Declaration for Testamentary Deposit
Word

  • 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.
  • Submit a copy of the trust document; as applicable.
Irrevocable Trust Deposits

Declaration for Irrevocable Trust
Word

  • Required for all deposits in the name of a trust totaling $250,000 or greater in the aggregate.
  • Submit a copy of the trust document.
Revocable Living Trust Deposits

Declaration for Revocable Living Trust
Word

  • Required for all deposits in the name of a trust totaling $250,000 or greater in the aggregate.
  • Submit a copy of the trust document.
Corporation, Partnership, or Unincorporated Association Deposit

Declaration of Independent Activity
Word

Declaration of Independent Activity for Unincorporated Association
Word

  • No affidavit or declaration is required.
  • The FDIC will notify the first-tier broker if one of these forms is needed. One of the Declaration of Independent Activity forms may be required by corporations, partnerships or unincorporated associations if the depositor states that the funds in two or more accounts are owned by separate entities.
Government Deposit (Public Unit)

Declaration for Government Deposit
Word

  • Required for all government deposits $250,000 or greater in the aggregate.
IRA and Keogh Deposits

Declaration for IRA/KEOGH Deposit
Word

  • 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.
Employee Benefit Plan Deposits

Declaration for Plan and Trust
Word

Declaration for Defined Contribution Plan
Word

Declaration for Defined Benefit Plan
Word

Declaration for Health and Welfare Plan
Word

  • 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 $250,000 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.


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."

Checklist

The Submission Checklist is one of the items that must accompany your information package.

checklist thumbnail
Submission Checklist - PDF

Deliveries

For overnight packages, please use the following address:

Federal Deposit Insurance Corporation
Attention: Susan Bridges
1601 Bryan Street
Dallas, TX  75201

Contact Us

Direct inquiries to:

bdclaims@fdic.gov

Susan Bridges at 972-761-8108

Cathy Davis at 972-761-2336

Stay Current

Subscribe to receive emails about the closing of FDIC insured financial institutions in which brokered deposits may be affected or changes to the Deposit Broker's Processing Guide.

Subscribe

Forms A-Z

Affidavit of Agency Account
PDF | Word

Declaration for Custodian Deposit
Word

Declaration for Defined Benefit Plan
Word

Declaration for Defined Contribution Plan
Word

Declaration for Government Deposit
Word

Declaration for Health and Welfare Plan
Word

Declaration for IRA/KEOGH Deposit
Word

Declaration for Irrevocable Trust
Word

Declaration for Joint Ownership Deposit
Word

Declaration for Plan and Trust
Word

Declaration for Power of Attorney
Word

Declaration for Revocable Living Trust
Word

Declaration for Testamentary Deposit
Word

Declaration of Independent Activity
Word

Declaration of Independent Activity for Unincorporated Association
Word

Skip Footer back to content