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

Federal Deposit Insurance Corporation 

DECLARATION OF AGENCY ACCOUNT

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 

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for 

reviewing instructions, and completing this form. Send comments regarding this burden estimate or any other aspect of this collection 

of information, including suggestions for reducing this burden to the Public Reporting Act Clearance Officer, Legal Division, Federal 

Deposit Insurance Corporation, 550 17th Street, N.W., Washington, DC 20429; and the Office of Management and Budget, Paperwork 

Reduction Project (3064-0122), 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

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. 

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

Federal Deposit Insurance Corporation 

DECLARATION OF AGENCY ACCOUNT

INSTRUCTIONS: See last page of form for full instructions.

SECTION I - FINANCIAL INSTITUTION INFORMATION

1. Name of Financial Institution 2. Closing Date

3. Account Number 4. City 5. State

SECTION II - DECLARATION

The undersigned, states as follows:

6. The undersigned is a of

(Title) (Name of Organization)

The undersigned is knowledgeable about all facts disclosed or addressed in this Declaration. The duties of the undersigned 

may be described as follows: 

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

 

(Name of Failed Institution) (City) (State)

as Agent for the persons or entities identified on the 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.]

8. 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.]

9. 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.]

10. This Declaration 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.

11. The undersigned affirms that all of the foregoing statements are correct and contain no material omission. By executing this 

Declaration 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 Declaration 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. 

12. This Declaration under penalty of perjury is executed pursuant to 28 U.S.C. § 1746.

Officer*

I declare under penalty of perjury that the foregoing is true and correct. Executed this day of , . 

(Name) (Signature)

Secretary or Assistant Secretary*

I declare under penalty of perjury that the foregoing is true and correct. Executed this day of , .

(Name) (Signature)

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

13. For processing purposes, please provide your firm's tax identification number:
FDIC 7200/22 (3-22) Page 3 of 3

SECTION III - EXHIBIT A

14. Complete the following.

Bank Account or 

CUSIP Number

Participant/Investor 

Name & Address

Tax ID 

Number

Amount Owned 

Principal

SECTION IV - EXHIBIT B

15. Provide your standard form of agency agreement or other written documentation to support the agency relationship.
FDIC 7200/22 (3-22) Page 3 of 3

INSTRUCTIONS FOR COMPLETING 

FORM FDIC 7200/22, DECLARATION OF AGENCY ACCOUNT

The Declaration of Agency Account is required from every broker (including ALL sub-tier brokers) and also requires two attachments 

i.e., an Exhibit A and Exhibit B. Below are the specifics for each Section. Additional information can be found within the Deposit 

Broker's Processing Guide. 

SECTION I - FINANCIAL INSTITUTION INFORMATION relates to the failed institution where you placed your deposit. If you have 

multiple Account Numbers, leave item 3 blank, then place the Account Numbers in Section III - Exhibit A or within your electronic 

file format. 

SECTION II - DECLARATION identifies the Officer who is knowledgeable about all facts disclosed or addressed in the Declaration 

and affirms that all statements are correct and the information contains no omissions. 

The second signature is that of the Secretary or Assistant Secretary who certifies that the undersigned Officer has the authority to 

execute the Declaration and other documents on behalf of the Agent. 

Item 13 is the firm's tax identification number and must also be included on this form for processing and payment purposes.

SECTION III - EXHIBIT A represents the customer ownership listing of investors and their interest (principal only) in the accounts 

at the time of the institution's failure OR you may also reference that the ownership information is included on the provided 

electronic file. 

The electronic file data must be in an ASCII-flat, tab delimited file, as outlined in our Deposit Broker's Processing Guide, Section V. 

Broker Input File Requirements. 

SECTION IV - EXHIBIT B represents your firms account set-up agreement(s) and demonstrates the relationship between you as 

Agent and each customer. This is also referenced in Section II, item 8 above. 

• These documents are provided solely by the Agent/firm and would represent their standard new account agreements 

executed by the firm and the deposit owner. 

• Often there are separate documents for each type of account i.e., IRA, trust etc. The collection of all the agreements can 

be provided to cover all account types on deposit at the failed institution. 

• If specific owner/account information is needed to determine the amount of deposit insurance on a particular account, you 

will subsequently be contacted.