OMB NUMBER: 3064-0143
EXPIRATION DATE: 07/31/2008
Federal Deposit Insurance Corporation
DECLARATION OF INDEPENDENT ACTIVITY
FOR UNINCORPORATED ASSOCIATION
INSTRUCTIONS: An executed copy of this Declaration of Independent Activity for Unincorporated Association must be
submitted before an insurance determination can be made on your Account. Please be sure to attach to this
Declaration of Independent Activity for Unincorporated Association all of the documentation requested in Item 6.
1. The undersigned is
(Name of Organization)
(the “Accountholder”) and is responsible for: (Describe Duties)
2. Under the FDIC’s regulations, an unincorporated association is deemed to exist for insurance purposes whenever
there is an association of two or more persons formed for some religious, educational, charitable, social or other
noncommercial purpose 12 C.F.R. § 330.12(c). The purpose of the Accountholder may be described as follows:
3. The source of funds for the above-listed Account was:
4. The members of the Accountholder are the following (do not complete if the number of members exceeds ten):
5. The officers of the Accountholder on the closing date were the following:
6. Attached are copies of the following: (1) the charter or bylaws of the Accountholder; and (2) evidence reflecting the tax-exempt
status of the Accountholder.
7. To the best knowledge of the undersigned, the Accountholder does not have an ownership interest, directly or indirectly, in any
other accounts at the closed institution.
8. The undersigned, or any one of them has (have) been authorized to execute and deliver to the Federal Deposit Insurance
Corporation (“FDIC”) information for the above-referenced Account at the named insti