Fill - Free fillable 7200-22 FDIC 7200/22, Affidavit of Agency Account PDF form

FDIC 7200/22 (5-12)

PRIVACY ACT STATEMENT

The Federal Deposit Insurance Act (12 U.S.C. §§1819, 1821, and 1822) and 12 C.F.R. Part 330 authorize the

collection of this information. The FDIC will use the information to assist in the determination of deposit

insurance coverage and/or the payment of deposit insurance on deposits of the closed financial institution. The

FDIC may disclose this information: 1) to other federal or state financial institution regulatory agencies, to the

financial institution which acquired the deposit accounts of the closed financial institution, if any, and to

contractors to assist in the determination and/or payment of deposit insurance on deposits of the closed financial

institution; 2) to appropriate Federal, State or local agency or responsible authority, to the extent that disclosure

is necessary and pertinent for investigating or prosecuting a violation of or for enforcing or implementing a

statute, rule, regulation or order, when the information indicates a violation or potential violation of law, whether

civil, criminal or regulatory in nature, and whether arising by any statute, or by regulation, rule or order issued

pursuant thereto; 3) to a court, magistrate, or administrative tribunal in the course of presenting evidence,

including disclosure to counsel or witnesses in the course of civil discovery, litigation, or settlement negotiations

or in connection with criminal law proceedings, when the FDIC is a party to the proceeding or has a significant

interest in the proceeding and the information is determined to be relevant and necessary; or 4) in accord with

any other routine use appropriate for the FDIC’s Insured Financial Institution Liquidation Records, # 30-64-0013.

Submitting this information to the FDIC is voluntary. Failure, however, to submit all of the information requested

and to complete the form entirely could delay or preclude the determination of deposit insurance coverage and/or

the payment of deposit insurance on deposits of the closed financial institution.

PAPERWORK REDUCTION ACT NOTICE

Public reporting burden for this collection of information is estimated to average 30 minutes per response,

including the time for reviewing instructions, and completing this form. Send comments regarding this burden

estimate or any other aspect of this collection of information, including suggestions for reducing this burden to

the Public Reporting Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17th

Street, N.W., Washington, DC 20429; and the Office of Management and Budget, Paperwork Reduction Project

(3064-0122), Washington, D.C. 20503. An agency 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 control number.

FDIC 7200/22 (5-12)

Financial Institution:

Closing Date:

Account Number:

Group Number:

STATE OF )

)

COUNTY OF )

AFFIDAVIT OF AGENCY ACCOUNT

The undersigned, being first duly sworn, deposes and states as follows:

1. The undersigned is a of

(Title) (Name of Organization)

The undersigned is knowledgeable about all facts disclosed or addressed in this affidavit. The duties of the undersigned may

be described as follows:

2. On , (Closing Date), the organization identified above held the above account(s) at

as Agent for the persons or entities identified on the

(

Name and location of the failed institution)

attached Exhibit A. The attached exhibit is a customer ownership list. For each customer, the exhibit includes the name,

address and tax identification number. Also, the exhibit discloses each customer’s ownership interest in the account(s)

(principal) as of the date of the insured depository institution’s failure. The principal balance is mandatory. [NOTE: You may

attach relevant portions of customer’s activity statements for recent months if you believe that such statements would be

helpful.]

3. The relationship between the Agent and each customer is governed by (1) the standard agreement attached as Exhibit B;

and/or (2) the non-standard agreement(s) attached or explained in Exhibit B. Pursuant to such agreements(s), the Agent

acted on behalf of the customers in placing deposits at the failed institution. [NOTE: You may attach “trade confirmations” or

similar documents if you believe that such documents would be helpful.]

4. The undersigned represents that the customers’ deposits are not part of a trust or other business arrangement which has filed

or is required to file a registration statement with the Securities and Exchange Commission pursuant to section 8 of the

Investment Company Act of 1940 or that would be required so to register but for the fact it was not created under the laws of

the United States or a state or but for sections 2(b), 3(c)(1), or 6(a)(1) of that Act. [NOTE: If you are unsure whether the

customer’s deposits are part of such a trust or business arrangement, please attach a statement addressing this issue.]

5. This Affidavit is made to induce the Federal Deposit Insurance Corporation to pay insurance on the Account(s) to the

extent that the Account(s) is/are covered by insurance.

6. The undersigned affirms that all of the foregoing statements are correct and contain no material omission. By executing this

Affidavit in the space below, the secretary or assistant secretary of the Agent hereby certifies that the undersigned has the

authority as a duly-elected and acting officer of the Agent to execute, on behalf of the Agent, this Affidavit and any and all

other documents which the FDIC may require to be executed in connection with the payment of insurance on the above

Account(s) and to bind the Agent by his or her action.

FDIC 7200/22 (5-12)

AFFIDAVIT OF AGENCY ACCOUNT (Continued)

7. This declaration under penalty or perjury is executed pursuant to 28 U.S.C. § 1746.

I declare under penalty of perjury that the foregoing

is true and correct.

Executed this day of _______________, ___

Executed this day of _________,

Signature of Secretary or Assistant Secretary*

Signature of Officer*

Printed Name

SUBSCRIBED AND SWORN TO BEFORE ME

THIS DAY OF ________________, ____

THIS DAY OF _______________ , ___

Notary Public in and for the above County and State

Printed Name of Notary

My Commission Expires:

For processing purposes, please provide your firm’s tax identification number:

NOTICE: Nothing in the payment of insurance by the FDIC in reliance on this Affidavit shall be construed in any way to limit or waive the ability of

the FDIC to recover any payment of insurance made in error or in excess of the statutory limit.

THE PENALTY FOR KNOWINGLY MAKING OR INVITING RELIANCE ON ANY FALSE, FORGED OR COUNTERFEIT

STATEMENT, DOCUMENT OR THING FOR THE PURPOSE OF INFLUENCING IN ANY WAY THE ACTION OF THE FEDERAL

DEPOSIT INSURANCE CORPORATION IS A FINE OF NOT MORE THAN $1,000,000 OR IMPRISONMENT FOR NOT MORE

THAN THIRTY YEARS, OR BOTH (18 U.S.C. § 1007).

*This applies only to an Agent who is a corporation or other entity.

FDIC 7200/22 (5-12)

AFFIDAVIT OF AGENCY ACCOUNT

EXHIBIT A

BANK ACCOUNT or

CUSIP Number

PARTICIPANT/INVESTOR

Name & Address

TAX ID

Number

AMOUNT OWNED

Principal

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7200-22 FDIC 720022, Affidavit of Agency Account

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