**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 7200/11

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| Federal Deposit Insurance Corporation                                 |
|                                                                       |
| **DECLARATION FOR IRA/KEOGH DEPOSIT**                                 |
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**INSTRUCTIONS**: Please type or print all information legibly, date,
and sign.

Financial Institution:      

Closing Date:      

Account Number:      

Group Number:      

# 

1.  The deposit referenced above (the "Account") was made in connection
    with the following type of retirement plan (*Check one*):

> An individual retirement account (IRA) described in section 408(a) of
> the Internal Revenue Code of 1986 (26 U.S.C. 408(a)).
>
> An eligible deferred compensation plan described in section 457 of the
> Internal Revenue Code of 1986 (26 U.S.C. 457).
>
> An individual account plan defined in section 3(34) of the Employee
> Retirement Income Security Act (ERISA) (29 U.S.C. 1002) or a plan
> described in section 401(d) of the Internal Revenue Code of 1986 (26
> U.S.C. 401(d)) for which participants or beneficiaries have the right
> to direct the investment of assets held in individual accounts
> maintained on their behalf by the plan.

2.  The trustee or administrator of the IRA or retirement plan is      
    (Name of bank or other qualified person). Documentary evidence
    reflecting the authority of the trustee or administrator to serve in
    this capacity is attached hereto. (Attach IRS determination letter
    or other appropriate evidence.)

3.  The undersigned is employed by the trustee or administrator in the
    following capacity:

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4.  The owner of the Account is       .

(Name of owner)

5.  The relationship between the trustee or administrator and the
    deposit owner is governed by the agreement(s) or document(s)
    attached hereto. (Attach the IRA or Keogh or other agreement(s) in
    effect on the closing date. If the agreement is very lengthy, attach
    a sufficient number of pages to establish that the trustee or
    administrator entered into an agreement with the deposit owner.)

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6.  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.

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7.  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:       .

> Signature of Trustee/Administrator

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  **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).**

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**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]{.underline} 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, 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. 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.