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||
|Joint Ownership Deposit||
|Irrevocable Trust Deposits||
|Revocable Living Trust Deposits||
|Corporation, Partnership, or Unincorporated Association Deposit||
|Government Deposit (Public Unit)||
|IRA and Keogh Deposits||
|Employee Benefit Plan Deposits||
Table of Contents
The Submission Checklist is one of the items that must accompany your information package.
For overnight packages, please use the following address:
Federal Deposit Insurance Corporation
Attention: Shelia Lollie
600 North Pearl, Suite 700
Dallas, TX 75201
Direct inquiries to:
Shelia Lollie at 972-761-8385
Nancy Clark at 972-761-2575
Jake Meyer at 972-761-8580
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