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

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. 287 and 31 U.S.C. 3729, respectively.

____________________________
Affiant (Signature)

Signed and sworn to (affirmed) before me

_________________________, this_________ day of _____________, 200_, by
(Notary Public)

________________________________.
(Affiant Name)

__________________________________My commission expires ________________________
NOTARY PUBLIC