OMB NUMBER: 3064-0143 EXPIRATION DATE: 07/31/2011
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 FDIC will use the information to assist in the determination of deposit insurance coverage and/or the payment of deposit insurance on deposits of the closed financial institution. The FDIC may disclose this information: 1) to other federal or state financial institution regulatory agencies, to the financial institution which acquired the deposit accounts of the closed financial institution, if any, and to contractors to assist in the determination and/or payment of deposit insurance on deposits of the closed financial institution; 2) to appropriate Federal, State or local agency or responsible authority, to the extent that disclosure is necessary and pertinent for investigating or prosecuting a violation of or for enforcing or implementing a statute, rule, regulation or order, when the information indicates a violation or potential violation of law, whether civil, criminal or regulatory in nature, and whether arising by any statute, or by regulation, rule or order issued pursuant thereto; 3) to a court, magistrate, or administrative tribunal in the course of presenting evidence, including disclosure to counsel or witnesses in the course of civil discovery, litigation, or settlement negotiations or in connection with criminal law proceedings, when the FDIC is a party to the proceeding or has a significant interest in the proceeding and the information is determined to be relevant and necessary; or 4) in accord with any other routine use appropriate for the FDIC’s Insured Financial Institution Liquidation Records, # 30-64-0013. Submitting this information to the FDIC is voluntary. Failure, however, to submit all of the information requested and to complete the form entirely could delay or preclude the determination of deposit insurance coverage and/or the payment of deposit insurance on deposits of the closed financial institution.
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OMB NUMBER: 3064-0143 EXPIRATION DATE: 07/31/2011
Federal Deposit Insurance Corporation
DECLARATION FOR DEFINED BENEFIT PLAN
INSTRUCTIONS: Please type or print all information legibly, date, and sign. Financial Institution: Closing Date: Account Number: Group Number:
1. The undersigned is the actuary for the Plan (the “Plan”) for which
account number was established at .
2. The undersigned is presently enrolled by the Joint Board for the Enrollment of Actuaries.
3. There were participants in the Plan on the closing date.
4. If the above account(s) had an aggregate balance of LESS than $102,000 on the closing date, did the present value of any
one participant’s accrued benefit (including rollover, other voluntary participant contributions and any other amounts held for
the benefit of the participant) exceed 95% of the total Plan assets on the closing date?
5. The largest percentage interest which any participant had in the Plan on the closing date was %. The name of such
participant is . The percentage interest in the Plan was determined by dividing the
present value of each participant’s accrued benefit (including rollover, other voluntary participant contributions and any other
amounts held for the benefit of the participant) by the total Plan assets.
6. The present value of all participants’ accrued benefits in the Plan (including rollover and other participant contributions) was at
least % and no greater than % of total Plan assets on the closing date.
7. The present value of each participant’s accrued benefit was determined for the purpose of this Declaration by using the
interest rate and mortality assumptions stated in the Plan.
8. The above account is an investment of (Please check one):
General Plan assets which are made on behalf of all participants in the Plan
Self-directed funds or segregated funds
9. Have any participants made voluntary participant contributions, rollover contributions or trustee-to-trustee transfers to the Plan
(excluding a trustee-to-trustee transfer from a plan with the same sponsor as the Plan discussed above)?
10. Attached is a copy of the most recent actuarial report for the Plan (only required if the account(s) for the Plan exceeds $102,000
or if there are any other accounts for an employee benefit plan with the same sponsor).
11. This declaration is made to induce the Federal Deposit Insurance Corporation to pay insurance covering the Account to the
extent that the Account is covered by insurance.
12. 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 .
Actuary Signature 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 closes in accordance to Deposit Insurance Rules and Regulations. Public reporting burden for this collection of information is estimated to average 1 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 threducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17 Street, N.W., Washington, D.C. 20429, and the Office of Management and Budget, Paper Reduction Act Project, 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.
FDIC 7200/12 (10-08)