CLAIMANT VERIFICATION
PRIVACY ACT STATEMENT
The Federal Deposit Insurance Act (12 U.S.C. §§ 1819, 1821, and 1822), Executive Order 9397, as amended, and 12 C.F.R. Part 330 authorize the collection of this information. The purpose for collecting this information is to support the determination of deposit insurance coverage and/or the payment of deposit insurance on deposits of the closed financial institution. Furnishing this information is voluntary but failure to provide the requested information in whole or in part may delay or prevent the determination of deposit insurance coverage and/or the payment of deposit insurance on deposits of the closed financial institution. The information provided by individuals is protected by the Privacy Act, 5 U.S.C. 552a. The information you provide may be provided to appropriate Federal, state, local or foreign law enforcement authorities; to a court, administrative tribunal, or a party in litigation; to contractors, agents and other third parties as authorized by law, and in accordance with any of the other routine uses described in the FDIC Insured Financial Institution Liquidation Records (FDIC-30-64-0013) System of Records. A complete copy of this System of Records is available at www.fdic.gov/about/privacy. If you have questions or concerns about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at Privacy@fdic.gov.
PAPERWORK REDUCTION ACT NOTICE
The information collected is required for the determination of insured deposits when a financial institution closes in accordance with the FDIC's deposit insurance regulations. Public reporting burden for this collection of information is estimated to average ½ hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Paperwork Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17th Street, N.W., Washington, D.C. 20429 and the Office of Management and Budget, Paperwork Reduction Project (3064-0143), Washington, D.C. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
FDIC 7200/24 (3-22) — Page 1 of 2
CLAIMANT VERIFICATION — Form FDIC 7200/24 (3-22), Page 2 of 2
Instructions: Complete this form if you have an unclaimed insured deposit and/or an outstanding dividend check associated with a Failed Financial Institution. Provide a copy of your driver's license and copies of any information that would help promptly identify your account. Submit forms electronically to Depositorservices@fdic.gov or by mail to the FDIC Claims Department at 600 North Pearl Street, Suite 700, Dallas, TX 75201. (Include all supporting documents at the same time.) For questions, contact the Depositor Claims Agent at 202-596-2167 or at Depositorservices@fdic.gov.
Note: FDIC will not collect any personal information about individuals except when specifically and knowingly provided by such individuals. Examples of such information are: name, address, e-mail address, phone number, etc. Your submitted information is for internal use only and will not be distributed to any other parties. FDIC will not sell, rent, or loan any identifiable information regarding clients to any third party. Any information you give is held with utmost care and security, and will not be used in ways to which you have not consented.