OMB NUMBER: 3064-0150
EXPIRATION DATE: 09/30/2007
Federal Deposit Insurance Corporation
DECLARATION FOR TRUST
INSTRUCTIONS: Please type or print all information legibly, date and sign. See page 2 for the Paperwork Reduction Act Notice.
Financial Institution:
Closing Date:
Account Number:
Group Number:
(Check One) Revocable Trust Irrevocable Trust
1. The undersigned is (are) trustee(s) of the attached Trust (the “Trust”) for which the above-referenced account(s) (the “Account(s)”)
was/were established.
2. The names of all of the trustee(s) of said Trust on the closing date were:
The attached is a true, exact and complete copy of the Trust, as in effect on the closing date.
3. The settlor(s)/grantor(s) of said Trust and their respective contributions are:
NAME PERCENTAGE OF FUNDS
(A)
(B)
100%
If a settlor/grantor is deceased, please give the name and date of the death of the settlor/grantor.
Name Date of Death
4. If the Trust is revocable, list the beneficiaries of the Trust and the relationship of each of them to each of the above-named
settlers/grantors:
NAME OF BENEFICIARY RELATIONSHIP TO (A) RELATIONS TO (B)
Each of the above-named beneficiaries is living. If any beneficiary is deceased, please indicate name and date of death:
NAME DATE OF DEATH
5. The undersigned, or any one of them has (have) the authority under the Trust to execute, on behalf of the Trust, this Declaration,
the claim form and all other documents which the Federal Deposit Insurance Corporation (“FDIC”) may require to be executed in
connection with the payment of insurance on the Account(s) and to bind the Trust by his or her action.
If not applicable, please check box. Not applicable
6. This declaration is made to induce the Federal Deposit Insurance Corporation to pay insurance covering the Account(s), to the
extent the Account(s) is (are) covered by insurance.
FDIC 7200/05 (9-04) Page 1 This form is not valid unless the OMB Clearance Number is displayed.
