Please respond to: NCUA-AMAC, 4807 Spicewood Springs Road, Suite 5100, Austin, TX 78759

MEMBER VERIFICATION

I may be the person you are looking for. Please compare this to your records and see if you are holding any money for me!

Name: ___________________________________________________________

Address: ___________________________________________________________

City, ST, ZIP: ___________________________________________________________

Telephone (____) _____-_____________

Social Security Number ________________________

Name of Credit Union __________________________________________________________

Signature __________________________________________________________

The bottom half of this form requires notarization. If you would like us to check your name, address and social security against our records, please fill out the above information. We will contact you if we need a notarized form.

AFFIDAVIT OF CLAIMANT

State of _________________}

County of _______________}

I, ________________________, do hereby solemnly swear (or affirm) that I had shares in a credit union that was liquidated by the National Credit Union Administration as indicated above.

I understand that presenting a false or fraudulent claim, in whole or in part, to the National Credit Union Administration for share insurance may subject me to criminal and/or civil penalties as provided for in 18 U.S.C. §287 and 31 U.S.C. §3729, respectively.

____________________________
AFFIANT (Signature)

Signed and sworn to (affirmed) before me

_________________________, this_________ day of _____________, 20___, by
(Notary Public)

________________________________.
(Affiant Name)

__________________________________My commission expires ________________________
NOTARY PUBLIC