OMB NUMBER: 3064-0143
EXPIRATION DATE: 05/31
/2013
FDIC 72
00
/13 (
11-09)
Federal Deposit Insurance Corporation
DECLARATION FOR CUSTODIAN DEPOSIT
INSTRUCTIONS: Please type or print legibly, date, and sign.
Financial Institution:
Closing Date:
Account Number:
Customer Number:
The undersigned, being of lawful age, declares as follows:
1. The undersigned is acting as custodian (the “Custodian”) for (the “Principal”)
who is my . The Principal is the owner of all the funds in the above-referenced account
(the “Account”).
2. There is no written agreement which sets forth the terms and conditions of the custodial relationship between the Custodian
and the Principal, except as may be attached hereto.
3. To the best knowledge of the undersigned, the Principal does not have an ownership interest in any other accounts at the
above institution, whether established by the Principal or by any other agent or custodian acting for the Principal, except as
noted here .
4. This declaration is made to induce the Federal Deposit Insurance Corporation to pay insurance covering the Account to the
extent that the Account is covered by insurance.
5. 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 Custodian (Please print) Signature of Custodian
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).
PAPERWORK REDUCTION ACT NOTICE
The information collected is required for the determination of insured deposits when a financial institution closes in accordance to Deposit
Insurance Rules and Regulations. Public reporting burden for this collection of information is estimated to average 1/2
hour per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Room MB-3082, Federal Deposit
Insurance Corporation, 550 17
th
Street, N.W., Washington, D.C. 20429. Any 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.
"INDICATE IF ANY OTHER ACCOUNTS"
