Deposit Broker's Processing Guide

Table of Contents

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 - PDF	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 - PDF	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 - PDF	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- PDF	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 - PDF	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 - PDF Declaration of Independent Activity for Unincorporated Association - PDF	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 - PDF	Required for all government deposits $250,000 or greater in the aggregate.
IRA and Keogh Deposits	Declaration for IRA/KEOGH Deposit - PDF	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 - PDF Declaration for Defined Contribution Plan - PDF Declaration for Defined Benefit Plan - PDF Declaration for Health and Welfare Plan - PDF	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: The pages of the Trust appointing the trustees and showing the trustees’ signatures, and Any one of: The Plan, The adoption agreement, or 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: If the Plan is a Defined Contribution Plan, please complete the Declaration for Defined Contribution Plan. 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: The account had more than $250,000 in it on the closing date; There are other accounts for an employee benefit plan with the same sponsor at the defaulted institution; or 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. If the Plan is a Health or Welfare Plan (medical, dental, life insurance, etc., benefits), please complete the Declaration for Health and Welfare Plan.

Table of Contents

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: Shelia Lollie
600 North Pearl, Suite 700
Dallas, TX 75201

Direct inquiries to:

bdclaims@fdic.gov

Shelia Lollie at 972-761-8385

Nancy Clark at 972-761-2575

Jake Meyer at 972-761-8580

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Forms A-Z

Affidavit of Agency Account - PDF

Declaration for Custodian Deposit - PDF

Declaration for Defined Benefit Plan - PDF

Declaration for Defined Contribution Plan - PDF

Declaration for Government Deposit - PDF

Declaration for Health and Welfare Plan - PDF

Declaration for IRA/KEOGH Deposit - PDF

Declaration for Irrevocable Trust - PDF

Declaration for Joint Ownership Deposit - PDF

Declaration for Plan and Trust - PDF

Declaration for Power of Attorney - PDF