Financial Institution:       

Closing Date:     

Account Number:     

Group Number:     

STATE OF                                                                           )

                                                                                                  )

COUNTY OF                                                                        )

**AFFIDAVIT OF AGENCY ACCOUNT**

The undersigned, being first duly sworn, deposes and states as follows:

1. The undersigned is a                                                                        of        

                                                            (Title)                                                                               (Name of Organization) 

The undersigned is knowledgeable about all facts disclosed or addressed in this affidavit.  The duties of the undersigned may be described as follows:  

2.On                                     ,          (Closing Date), the organization identified above held the above account(s) at

                                                                                                         as Agent for the persons or entities identified on the        

                          (Name and location of the failed institution)

attached Exhibit A.  The attached exhibit is a customer ownership list.  For each customer, the exhibit includes the name, address and tax identification number.  Also, the exhibit discloses each customer’s ownership interest in the account(s) (principal) as of the date of the insured depository institution’s failure.  The principal balance is mandatory.  [NOTE: You may attach relevant portions of customer’s activity statements for recent months if you believe that such statements would be helpful.]

3.The relationship between the Agent and each customer is governed by (1) the standard agreement attached as Exhibit B; and/or (2) the non-standard agreement(s) attached or explained in Exhibit B.  Pursuant to such agreements(s), the Agent acted on behalf of the customers in placing deposits at the failed institution. [NOTE: You may attach “trade confirmations” or similar documents if you believe that such documents would be helpful.]

4.The undersigned represents that the customers’ deposits are not part of a trust or other business arrangement which has filed or is required to file a registration statement with the Securities and Exchange Commission pursuant to section 8 of the Investment Company Act of 1940 or that would be required so to register but for the fact it was not created under the laws of the United States or a state or but for sections 2(b), 3(c)(1), or 6(a)(1) of that Act.  [NOTE:  If you are unsure whether the customer’s deposits are part of such a trust or business arrangement, please attach a statement addressing this issue.]

5.This Affidavit is made to induce the Federal Deposit Insurance Corporation to pay insurance on the Account(s) to the extent that the Account(s) is/are covered by insurance.

6.The undersigned affirms that all of the foregoing statements are correct and contain no material omission.  By executing this Affidavit in the space below, the secretary or assistant secretary of the Agent hereby certifies that the undersigned has the authority as a duly-elected and acting officer of the Agent to execute, on behalf of the Agent, this Affidavit and any and all other documents which the FDIC may require to be executed in connection with the payment of insurance on the above Account(s) and to bind the Agent by his or her action.

**AFFIDAVIT OF AGENCY ACCOUNT** (Continued)

7. This declaration under penalty or perjury is executed pursuant to 28 U.S.C. § 1746.

**For processing purposes, please provide your firm’s tax identification number:**

NOTICE:  Nothing in the payment of insurance by the FDIC in reliance on this Affidavit shall be construed in any way to limit or waive the ability of the FDIC to recover any payment of insurance made in error or in excess of the statutory limit.

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).

*This applies only to an Agent who is a corporation or other entity.

**AFFIDAVIT OF AGENCY ACCOUNT**

**EXHIBIT A**

FDIC 7200/22 (5-12)