OMB NUMBER: 3064-0143
EXPIRATION DATE: 05/31/2017
INSTRUCTIONS: Please type or print all information legibly, date, and sign.
Financial Institution:
Closing Date:
Account Number(s):
Customer Number:
1. The undersigned is the trustee or administrator for the
Plan (the "Plan"), for which the above account(s) was (were) established at the above insured depository institution. (If the
undersigned is not the trustee or administrator for the Plan, please attach an explanation as to why the undersigned and not
the administrator has completed this form.)
2. The Plan is a defined benefit plan sponsored by
Also, it is an “employee benefit plan” as that term is defined in section 3(3) of the Employee Retirement Income Security Act of
1974 (29 U.S.C. § 1002). Attached is a copy of the most recent actuarial report for the Plan (only required if the total balance
of the account or accounts exceeds $250,000 or if there were any other accounts at the failed institution for other employee
benefit plans sponsored by the same employer).
3. The above account or accounts represent an investment of general Plan assets for the benefit of all participants in the Plan.
The accounts do not represent self-directed funds or segregated funds for particular participants. (If the accounts represent
self-directed funds or segregated funds for particular participants, you should attach a separate report that reflects (A) the
names of the Plan participants for whom the accounts were held; and (B) the amount held in the accounts for each such
participant. Also, you should attach copies of the agreements that authorize these participants to direct funds into the
accounts or to serve as beneficiaries of the segregated funds in the accounts.)
4. On the closing date, the value of all general Plan assets (including but not limited to the deposits in the above account(s))
5. The insurance coverage of the deposits of an employee benefit plan is governed by 12 C.F.R. § 330.14. Under that section of
the FDIC’s insurance regulations, the deposits must be divided into the following categories: (1) funds representing the “non-
contingent interests” (as defined below) of the Plan participants; (2) funds representing the “contingent interests” of the Plan
participants; and (3) funds representing any “overfunding” of the Plan. In this case, the value of all general Plan assets
(including but not limited to the deposits in the above account(s)) can be divided as follows:
Combined dollar amount of participants’ “non-contingent interests”:
Dollar amount of contingent interests:
Dollar amount of overfunding:
6. On the closing date the number of participants in the Plan was
7. In the case of a defined contribution plan, an employee’s “non-contingent interest” is “deemed to be the present value of the
employee’s interest in the plan, evaluated in accordance with the method of calculation ordinarily used under such plan, as of the
date of default of the insured depository institution. 12 C.F.R. § 330.14(c)(2). Under this definition, the participant with the largest
“non- contingent interest” in the Plan on the closing date was
His/her percentage interest in the Plan on the closing date was
This percentage interest was determined by dividing the participant’s “non-contingent interest” by the total Plan assets.
8. The figures given above are based upon the interest rate and mortality assumptions stated in the Plan.
9. The declaration is made to induce the Federal Deposit Insurance Corporation to pay insurance covering the above account(s) to
the extent provided by law.
10. This declaration, under penalty of perjury, is executed pursuant to 28 U.S.C. § 1746.
I declare under penalty of perjury that the foregoing is true and correct. Executed on
Name of Trustee or Administrator (Please print)
Signature of Trustee or Administrator
FDIC 7200/12 (5-14) Page 1
Federal Deposit Insurance Corporation
DECLARATION FOR DEFINED BENEFIT PLAN
