Declaration for Defined Benefit Plan

• Legal Form Number: FDIC 7200/12
• Section: Federal Deposit Insurance Corporation

FDIC 7200/12 (3-22)

OMB Number: 3064-0143

Expiration Date: 09/30/2023

Page 1 of 3

Federal Deposit Insurance Corporation

DECLARATION FOR DEFINED BENEFIT PLAN

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 atwww.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 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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