FDIC 7200/06 (3-22)

OMB Number: 3064-0143 

Expiration Date: 12/31/2026

Page 1 of 3

Federal Deposit Insurance Corporation 

DECLARATION OF INDEPENDENT ACTIVITY

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 purpose for collecting this information is to support the determination of deposit insurance coverage and/or the 

payment of deposit insurance on deposits of the closed financial institution. Furnishing this information is voluntary but failure to 

provide the requested information in whole or in part may delay or prevent the determination of deposit insurance coverage and/or the 

payment of deposit insurance on deposits of the closed financial institution. The information provided by individuals is protected by the 

Privacy Act, 5 U.S.C. 552a. The information you provide may be provided to appropriate Federal, state, local or foreign law 

enforcement authorities; to a court, administrative tribunal, or a party in litigation; to contractors, agents and other third parties as 

authorized by law, and in accordance with any of the other routine uses described in the FDIC Insured Financial Institution Liquidation 

Records (FDIC-30-64-0013) System of Records. A complete copy of this System of Records is available at www.fdic.gov/about/

privacy. 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. 

PAPERWORK REDUCTION ACT NOTICE 

The information collected is required for the determination of insured deposits when a financial institution closes in accordance with the 

FDIC's deposit insurance 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 Paperwork Reduction Act Clearance Officer, Legal 

Division, Federal Deposit Insurance Corporation, 550 17th 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.

NOTE: 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). 

Page down to access form 7200/06 
FDIC 7200/06 (3-22)

OMB Number: 3064-0143 

Expiration Date: 12/31/2026

Page 2 of 3

Federal Deposit Insurance Corporation 

DECLARATION OF INDEPENDENT ACTIVITY

INSTRUCTIONS: The FDIC provides the Depositor ID (ID is an internal, system-generated identifier). Submit forms electronically to 

Depositorservices@fdic.gov or by mail to the FDIC Claims Department at 600 North Pearl Street, Suite 700, Dallas, TX 75201. 

(Include all supporting documents at the same time). For questions, contact Depositor Claims Agent at 972-761-2112 or at 

Depositorservices@fdic.gov.

SECTION I - FINANCIAL INSTITUTION

1. Name 2. Closing Date

3. Account Number 4. Depositor ID

SECTION II - DECLARATION

5. The undersigned is of 

(the "Accountholder") and is responsible for:

Describe Duties

(Title) (Name of Organization)

6. The Accountholder is engaged in the business of:

7. The source of funds for the above-listed Account was:
FDIC 7200/06 (3-22)

OMB Number: 3064-0143 

Expiration Date: 12/31/2026

Page 3 of 3

8. The major stockholders (if the Accountholder is a corporation) or partners (if the Accountholder is a partnership) of the 

Accountholder and their percentage ownership interest were the following on the closing date:

9. The officers and directors of the Accountholder on the closing date were the following:

10. Attach the following: 

a. A copy of the certificate of good standing from the Secretary of State of incorporation dated no earlier than one year prior to 

the closing date or the certificate of partnership filed with the proper governmental authority; and 

b. A copy of the Articles of Incorporation or Partnership Agreement (whichever is applicable) for the Accountholder; and 

c. The most recent separate income tax return filed with the Internal Revenue Service or the most recent financial statements.

11. Does the Accountholder have an ownership interest, directly or indirectly, in any other accounts at the closed institution?

 Yes No If Yes, provide Account Number:

12. The undersigned, or any one of them has (have) been authorized to execute and deliver to the Federal Deposit Insurance 

Corporation (“FDIC”) information concerning the above-referenced Account at the closed 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 such Account and to 

subrogate to the FDIC the Accountholder's rights in said Account to the extent such Account is insured. If not applicable, please 

select box. Not Applicable

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

insurance.

14. 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)