OMB Number: 3074-0143
Expiration Date: 07/31/2008
Federal Deposit Insurance Corporation
DECLARATION FOR GOVERNMENT DEPOSIT
INSTRUCTIONS: Please type or print all information legibly and sign. See page 2 for the Paperwork Reduction Act Notice.
I am (We are) the official custodian(s) of
(the “Public Unit”), which is the
owner of the referenced deposit at the closed institution. Under the FDIC’s regulation at 12 C.F.R. § 330.15, an “official
custodian” is defined as a custodian with “plenary authority, including control, over funds owned by the public unit which the
custodian is appointed or elected to serve. Control of public funds includes possession, as well as the authority to establish
accounts for such funds in insured depository institutions and to make deposits, withdrawals, and disbursements of such funds.”
12 C.F.R. § 330.15(b)(1). I (We) have been appointed official custodian by statute, ordinance or
A copy of the relevant statute, ordinance or other authority is attached. The funds in the account have been lawfully invested at
the closed institution pursuant to statute, ordinance or
A copy of the relevant statute, ordinance or other authority is attached.
The deposit was owned by (check one of the following):
The United States of America
A state of the United States
The District of Columbia
The Commonwealth of Puerto Rico, the Virgin Islands, American Samoa, the Trust Territory of the Pacific Islands,
Guam, or The Commonwealth of the Northern Mariana Islands, or any county or municipality thereof.
A “political subdivision” of a public unit mentioned in (B), (C), (D), (E) or (F) above. Under the FDIC’s regulation at
12 C.F.R. § 330.15, a “political subdivision” is defined to include “drainage, irrigation, navigation, improvement,