**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.

Page down to access form FDIC 7200/07

+-----------------------------------------------------------------------+
| Federal Deposit Insurance Corporation                                 |
|                                                                       |
| **DECLARATION OF INDEPENDENT ACTIVITY**                               |
|                                                                       |
| **FOR UNINCORPORATED ASSOCIATION**                                    |
+-----------------------------------------------------------------------+
| **INSTRUCTIONS**: An executed copy of this Declaration of Independent |
| Activity for Unincorporated Association must be submitted before an   |
| insurance determination can be made on your Account. Please be sure   |
| to attach to this                                                     |
|                                                                       |
| Declaration of Independent Activity for Unincorporated Association    |
| all of the documentation requested in Item 6.                         |
+-----------------------------------------------------------------------+

Financial Institution:      

Closing Date:      

Account Number:      

Group Number:      

1.  The undersigned is       of      

> (Title) (Name of Organization)

      (the "Accountholder") and is responsible for: (Describe Duties)

     

     

2.  Under the FDIC's regulations, an unincorporated association is
    deemed to exist for insurance purposes whenever there is an
    association of two or more persons formed for some religious,
    educational, charitable, social or other noncommercial purpose 12
    C.F.R. § 330.12(c). The purpose of the Accountholder may be
    described as follows:

     

     

3.  The source of funds for the above-listed Account was:

>      

     

4.  The members of the Accountholder are the following (do not complete
    if the number of members exceeds ten):

>      

     

5.  The officers of the Accountholder on the closing date were the
    following:

     

     

6.  Attached are copies of the following: (1) the charter or bylaws of
    the Accountholder; and (2) evidence reflecting the tax-exempt status
    of the Accountholder.

7.  To the best knowledge of the undersigned, the Accountholder does not
    have an ownership interest, directly or indirectly, in any other
    accounts at the closed institution.

8\. The undersigned, or any one of them has (have) been authorized to
execute and deliver to the Federal Deposit Insurance Corporation
("FDIC") information for the above-referenced Account at the named
institution and to take any and all other actions and to execute any and
all other documents in connection with the payment of insurance on said
Account and to subrogate to the FDIC the Accountholder's rights in said
Account to the extent said Account is insured. If not applicable, please
check box.

> Not Applicable

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

FDIC 7200/07 (10-08) Page 1

# DECLARATION OF INDEPENDENT ACTIVITY FOR UNINCORPORATED ASSOCIATION (Continued)

9\. The declaration is made to induce the FDIC to pay insurance covering
the Account to the extent that the Account is covered by insurance.

10. This declaration, under penalty of perjury, is executed pursuant to
    28 U.S.C. § 1746.

I declare under penalty of perjury under the laws of the United States
of America that the foregoing is true and correct. Executed on:      

> Signature
>
>      
>
> Print Name

**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 [30]{.underline}
  minutes 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,
  Federal Deposit Insurance Corporation, 550 17^th^ Street, N.W.,
  Washington, D.C. 20429 and the Office of Management and Budget,
  Paperwork Reduction Project (3064-0143), 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 7200/07 (10-08) Page 2