Please mail inquiries to: FDIC, Attention: Unclaimed Funds, 1601 Bryan Street, Dallas, TX 75201
| FDIC CLAIMANT VERIFICATION |
Current Name: __________________________________________ FDIC Reference #________
Other Name used at Institution (if different than current)__________________________________
Current Address: _______________________________________________________________
City___________________________ State_____________________ Zip__________________
Telephone (____) _____-_____________
Social Security Number________________________Signature_____________________________________________________________________
Name of Financial Institution _____________________________________________________
_City of Financial Institution_____________________
_State of Financial Institution____________| AFFIDAVIT OF CLAIMANT |
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State of _________________} County of _______________} I, ________________________, do hereby solemnly swear (or affirm) that I am a depositor, general creditor, or shareholder of a financial institution that was liquidated by the Federal Deposit Insurance Corporation as indicated above. I understand that presenting a false or fraudulent claim, in whole or in part, to the Federal Deposit Insurance Corporation may subject me to criminal and/or civil penalties as provided for in 18 U.S.C. �7 and 31 U.S.C. �29, respectively. ____________________________ Affiant (Signature) Signed and sworn to (affirmed) before me _________________________, this_________ day of _____________, 200_, by ________________________________. (Affiant Name) __________________________________My commission expires ________________________ NOTARY PUBLIC |