Federal Deposit Insurance Corporation
DECLARATION FOR POWER OF ATTORNEY
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 [email protected].
PAPERWORK REDUCTION ACT NOTICE
The information collected is required for the 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 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. Any 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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FDIC 7200/16 (3-22) Page 1 of 2
Federal Deposit Insurance Corporation
DECLARATION FOR POWER OF ATTORNEY
INSTRUCTIONS: The FDIC provides the Depositor ID (ID is an internal, system-generated identifier). Submit forms electronically to
[email protected] 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
[email protected].
SECTION I - FINANCIAL INSTITUTION
1. Name 2. Closing Date
3. Account Number 4. Depositor ID
SECTION II - DECLARATION
5. I, , being of lawful age, declare that attached hereto is a true and correct copy of the Power
of Attorney appointing me as attorney-in-fact for (the “Principal”).
6. I further declare that I have no knowledge of the revocation or termination of the Power of Attorney, nor has it been terminated by
the death, disability or incompetence of the Principal.
7. Attach a copy of the Power of Attorney to this Declaration.
8. This declaration is made to induce the Federal Deposit Insurance Corporation to pay insurance covering the above-referenced
Account to the extent that the Account is covered by insurance.
9. 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: .
(Attorney-in-Fact Name) (Attorney-in-Fact Signature)
FDIC 7200/16 (3-22) Page 2 of 2
