OMB NUMBER: 3064-0150 

 EXPIRATION DATE: 09/30/2007 

Federal Deposit Insurance Corporation 

DECLARATION FOR TRUST

INSTRUCTIONS: Please type or print all information legibly, date and sign. See page 2 for the Paperwork Reduction Act Notice. 

Financial Institution: 

Closing Date: 

Account Number: 

Group Number: 

(Check One) Revocable Trust Irrevocable Trust 

1. The undersigned is (are) trustee(s) of the attached Trust (the “Trust”) for which the above-referenced account(s) (the “Account(s)”) 

was/were established. 

2. The names of all of the trustee(s) of said Trust on the closing date were: 

 

 

The attached is a true, exact and complete copy of the Trust, as in effect on the closing date. 

3. The settlor(s)/grantor(s) of said Trust and their respective contributions are: 

 NAME PERCENTAGE OF FUNDS 

(A) 

(B) 

 100% 

If a settlor/grantor is deceased, please give the name and date of the death of the settlor/grantor. 

 

Name Date of Death 

4. If the Trust is revocable, list the beneficiaries of the Trust and the relationship of each of them to each of the above-named 

settlers/grantors: 

NAME OF BENEFICIARY RELATIONSHIP TO (A) RELATIONS TO (B) 

 

Each of the above-named beneficiaries is living. If any beneficiary is deceased, please indicate name and date of death: 

NAME DATE OF DEATH 

 

5. The undersigned, or any one of them has (have) the authority under the Trust to execute, on behalf of the Trust, this Declaration, 

the claim form and all other documents which the Federal Deposit Insurance Corporation (“FDIC”) may require to be executed in 

connection with the payment of insurance on the Account(s) and to bind the Trust by his or her action. 

If not applicable, please check box. Not applicable 

6. This declaration is made to induce the Federal Deposit Insurance Corporation to pay insurance covering the Account(s), to the 

extent the Account(s) is (are) covered by insurance. 

FDIC 7200/05 (9-04) Page 1 This form is not valid unless the OMB Clearance Number is displayed.
 

DECLARATION FOR TRUST (Continued)

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: . 

 

Trustee Trustee 

Note: Please be sure to attach this Declaration to the copy of the Trust. 

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 close in accordance to Deposit Insurance 

Rules and Regulations. Public reporting burden for this collection of information is estimated to average 30 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, Room MB 3082, Federal Deposit Insurance 

Corporation, 550 17th Street, N.W., Washington, D.C. 20429.

FDIC 7200/05 (9-04) Page 2 This form is not valid unless the OMB Clearance Number is displayed.