Instructions for filing Proof of Claim (FDIC Form 7200/19e) 

INSTRUCTIONS: The following fields MUST be completed in order for your Proof of Claim (POC) 

to be considered. (The numbers correspond with those located on the actual Proof of Claim.) 

1. SSN/TAX ID NO. The Claimant’s tax identification number (if a company) or his/her Social Security

Number (if an individual).

2. NAME OF PERSON COMPLETING THE PROOF OF CLAIM. Self-explanatory.

3. NAME OF THE CLAIMANT. This is the person or entity actually making the claim. This may be you

or another person or entity on whose behalf you are authorized to file the claim.

4. AMOUNT OF CLAIM. The dollar amount of the claim.

5. DESCRIPTION OF CLAIM. Detailed description of what is being claimed (e.g., the invoice number,

type of service being claimed, account number, etc.). Additional information may be attached.

6. SIGNATURE. The signature of the person completing the POC. Include your title if you are filing this

POC on behalf of the Claimant.

7. DATE. Date the form is signed.

8. FIRM. If you are filing this POC on behalf of the Claimant, include the name of your company or firm,

if applicable.

9. ADDRESS. The address (including City, State, and ZIP code) of the individual completing this POC.

10. TELEPHONE NUMBERS. Telephone number of the individual completing this POC.

REQUIRED SUPPORTING DOCUMENTATION 

• Claims for Goods Purchased by the Failed Institution: You must enclose a copy of the purchase

order or other correspondence from the Failed Institution requesting the goods, a copy of your

invoice, and a receipt signed by the Failed Institution (or other evidence) indicating that the goods

were received.

• Claims for Services Rendered: You must enclose a copy of the correspondence or signed initial

contract sent by the Failed Institution to request your services and an invoice. In the case of law

firms (or other professional firms) retained by the Failed Institution, enclose an itemized invoice

detailing charges accruing prior to failure. For appraisal services, enclose proof that the appraisal

was completed.

• Other Types of Claims: You must enclose a copy of documents that substantiate the nature and

amount of the claim. While you may enclose a copy of the complaint that you filed with a court, this

alone is not sufficient to establish your claim.

SUBMITTING YOUR CLAIM 

There are two ways to submit your claim: 

Online:	 

(recommended) 

By Mail:	 

FDIC NDCWeb: https://www5.fdic.gov/NDCWeb 

Electronically file your claim via the internet by completing an online Proof of Claim 

form and attaching supporting documentation. Submitting your claim via the FDIC 

website is convenient, secure, and inexpensive, and will also help to expedite the 

handling of your claim. It is highly recommended. 

FDIC as Receiver for City National Bank of New Jersey

Attention: Claims Agent 

1601 Bryan Street 

Dallas, TX 75201 

If you choose this option, we recommend you send all documentation by U.S. 

certified mail or a commercial service that can provide you with a receipt of delivery. 

Please ensure that the Proof of Claim be the top document of your mailing. There is 

no need for a cover letter. Please do not send originals. 

View next page to access form FDIC 7200/19e 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROOF OF CLAIM 

Federal Deposit Insurance Corporation 

as Receiver for 

10534 – City National Bank of New Jersey, Newark, NJ

1. SSN/Tax ID No.

2. The undersigned

(Name of person completing the Proof of Claim) 

hereby states that the subject Financial Institution, now in liquidation (“Failed Institution”), is indebted 

3. (the “Claimant”) in the sum of to 

(Name of Claimant) 

4. $

(Amount of Claim) 

5. Description of Claim

The undersigned further states that no part of said debt has been paid, that the Claimant has given no endorsement or assignment of 

the same or any part thereof, and that there is no set-off or counterclaim, or other legal or equitable defense to said claim or any part 

thereof. 

6. NAME 7. DATE

(Name, Title, and Signature of person completing the Proof of Claim) 

8. FIRM

(Complete if filing on behalf of claimant) 

9. ADDRESS

(City, State, and ZIP Code) 

10. TELEPHONE NUMBER(S)

The penalty for knowingly making or inviting reliance on a 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 30 years or both (18 U.S.C. Section 1007). 

IMPORTANT NOTE: If you have other unrelated claims, you must file a separate Proof of Claim. Re-use of this Proof of Claim may result in 

processing delays or the rejection of your claim. 

PRIVACY ACT STATEMENT 

The FDIC is authorized to request this information from you by 12 U.S.C. § 1819, 1821, and Executive Order 9397. The purpose for 

collecting the information is to support the administration of claims against the failed financial institution. Furnishing the requested 

information is voluntary, but failure to provide the requested information in whole or in part may delay or prohibit the processing of your 

claim. The information provided by individuals is protected by the Privacy Act, 5 USC 552(a). The information may be furnished to third 

parties as authorized by law or used according to any of the routine uses described in the FDIC Insured Financial Institution Liquidation 

Records (30-64-0013) System of Records. This System of Records is available for review at https://www.fdic.gov/regulations/laws 

/rules/2000-4000.html# fdic200030--64--0013. If you have questions or concerns about the collection or use of the information, you may 

contact the FDIC’s Chief Privacy Officer at Privacy@fdic.gov. 

FDIC 7200/19e (12-12)