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 |
|
Custodian Account | Declaration for Custodian Deposit |
|
Joint Ownership Deposit | Declaration for Joint Ownership Deposit |
|
Testamentary Deposit | Declaration for Testamentary Deposit |
|
Irrevocable Trust Deposits | Declaration for Irrevocable Trust |
|
Revocable Living Trust Deposits | Declaration for Revocable Living Trust |
|
Corporation, Partnership, or Unincorporated Association Deposit | Declaration of Independent Activity Declaration of Independent Activity for Unincorporated Association |
|
Government Deposit (Public Unit) | Declaration for Government Deposit |
|
IRA and Keogh Deposits | Declaration for IRA/KEOGH Deposit |
|
Employee Benefit Plan Deposits | Declaration for Plan and Trust Declaration for Defined Contribution Plan Declaration for Defined Benefit Plan Declaration for Health and Welfare Plan |
|
Table of Contents
Checklist
The Submission Checklist is one of the items that must accompany your information package.
Deliveries
For overnight packages, please use the following address:
Federal Deposit Insurance Corporation
Attention: Shelia Lollie
600 North Pearl, Suite 700
Dallas, TX 75201
Contact Us
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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Forms A-Z
Affidavit of Agency Account
PDF
Electronic Submission for FDIC 7200/22
Declaration for Custodian Deposit
PDF
Electronic Submission for FDIC 7200/13
Declaration for Defined Benefit Plan
PDF
Electronic Submission for FDIC 7200/12
Declaration for Defined Contribution Plan
PDF
Electronic Submission for FDIC 7200/10
Declaration for Government Deposit
PDF
Electronic Submission for FDIC 7200/04
Declaration for Health and Welfare Plan
PDF
Electronic Submission for FDIC 7200/14
Declaration for IRA/KEOGH Deposit
PDF
Electronic Submission for FDIC 7200/11
Declaration for Irrevocable Trust
PDF
Electronic Submission for FDIC 7200/18
Declaration for Joint Ownership Deposit
PDF
Electronic Submission for FDIC 7200/08
Declaration for Plan and Trust
PDF
Electronic Submission for FDIC 7200/15
Declaration for Power of Attorney
PDF
Electronic Submission for FDIC 7200/16
Declaration for Revocable Living Trust
PDF
Electronic Submission for FDIC 7200/05
Declaration for Testamentary Deposit
PDF
Electronic Submission for FDIC 7200/09
Declaration of Independent Activity
PDF
Electronic Submission for FDIC 7200/06
Declaration of Independent Activity for Unincorporated Association
PDF
Electronic Submission for FDIC 7200/07