OMB Number: 3064-0143 

Expiration Date: 12/31/2026

FDIC 7200/04 (3-22) Page 1 of 3

Federal Deposit Insurance Corporation 

DECLARATION FOR GOVERNMENT DEPOSIT

PRIVACY ACT STATEMENT

The Federal Deposit Insurance Act (12 U.S.C. §§ 1819, 1821, and 1823) authorize collection of this information. The 

FDIC will use the information to respond to your request for assistance regarding the receivership estate of a failed 

financial institution. Furnishing this information is voluntary but failure to provide the requested information in whole or in 

part may delay or prevent the requested assistance or other response to your request. 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 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). 

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OMB Number: 3064-0143 

Expiration Date: 12/31/2026

FDIC 7200/04 (3-22) Page 2 of 3

Federal Deposit Insurance Corporation 

DECLARATION FOR GOVERNMENT DEPOSIT

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. I am (We are) the official custodian(s) of       (the “Public Unit”), which is 

the owner of the referenced account at the closed institution. Under the FDIC's regulation at 12 C.F.R. § 330.15, an 

“official custodian” is defined as a custodian with “plenary authority, including control, over funds owned by the public 

unit which the custodian is appointed or elected to serve. Control of public funds includes possession, as well as the 

authority to establish accounts for such funds in insured depository institutions and to make deposits, withdrawals, 

and disbursements of such funds.” 12 C.F.R. § 330.15(b)(1). I (We) have been appointed official custodian by 

statute, ordinance or                   .

                                                                                    .

A copy of the relevant statute, ordinance or other authority is attached. The funds in the account have been lawfully 

invested at the closed institution pursuant to statute, ordinance, or 

6. The account was owned by:

A. The United States of America

B. A state of the United States

C. A county

D. A municipality

E. The District of Columbia

F. The Commonwealth of Puerto Rico, the Virgin Islands, American Samoa, the Trust Territory of the Pacific 

Islands, Guam, or The Commonwealth of the Northern Mariana Islands, or any county or municipality thereof.

G. A “political subdivision” of a public unit mentioned in (B), (C), (D), (E) or (F) above. Under the FDIC's 

regulation, 12 C.F.R. § 330.15, a “political subdivision” is defined to include “drainage, irrigation, navigation, 

improvement, levee, sanitary, school or power districts, and bridge or port authorities and other special districts 

created by state statute or compacts between the states.” 12 C.F.R. § 330.15(d). The term also includes any 

subdivision of a public unit mentioned in (B), (C), (D), (E) or (F) or any principal department of such public unit 

that satisfies the following criteria: “(1) The creation of which subdivision or department has been expressly 

authorized by the law of such public unit; (2) To which some functions of government have been delegated by 

such law; and (3) Which is empowered to exercise exclusive control over funds for its exclusive use.”

H. An Indian Tribe (as defined in 25 U.S.C. § 1452(c))
OMB Number: 3064-0143 

Expiration Date: 12/31/2026

FDIC 7200/04 (3-22) Page 3 of 3

7. To the best knowledge of the undersigned, the Public Unit does not have an ownership interest in any other accounts 

at the closed Institution whether established by the official custodian or any other person, except for the accounts 

listed here:

8. This declaration is made to induce the Federal Deposit Insurance Corporation to pay insurance covering the deposit 

to the extent that the deposit is covered by insurance.

9. This declaration, under penalty of perjury, is executed pursuant to 28 U.S.C. § 1746.

I (We) declare, under penalty of perjury, that the foregoing is true and correct. Executed on: .

(Official Custodian Signature - 1) (Official Custodian Signature - 2)

(Title - 1) (Title - 2)