Instructions for filing Proof of Claim (FDIC Form 7200/19e)
INSTRUCTIONS: The following fields MUST be completed in order for your Proof of Claim (POC)
to be considered. (The numbers correspond with those located on the actual Proof of Claim.)
1. SSN/TAX ID NO. The Claimant’s tax identification number (if a company) or his/her Social Security
Number (if an individual).
2. NAME OF PERSON COMPLETING THE PROOF OF CLAIM. Self-explanatory.
3. NAME OF THE CLAIMANT. This is the person or entity actually making the claim. This may be you
or another person or entity on whose behalf you are authorized to file the claim.
4. AMOUNT OF CLAIM. The dollar amount of the claim.
5. DESCRIPTION OF CLAIM. Detailed description of what is being claimed (e.g., the invoice number,
type of service being claimed, account number, etc.). Additional information may be attached.
6. SIGNATURE. The signature of the person completing the POC. Include your title if you are filing this
POC on behalf of the Claimant.
7. DATE. Date the form is signed.
8. FIRM. If you are filing this POC on behalf of the Claimant, include the name of your company or firm,
if applicable.
9. ADDRESS. The address (including City, State, and ZIP code) of the individual completing this POC.
10. TELEPHONE NUMBERS. Telephone number of the individual completing this POC.
REQUIRED SUPPORTING DOCUMENTATION
• Claims for Goods Purchased by the Failed Institution: You must enclose a copy of the purchase
order or other correspondence from the Failed Institution requesting the goods, a copy of your
invoice, and a receipt signed by the Failed Institution (or other evidence) indicating that the goods
were received.
• Claims for Services Rendered: You must enclose a copy of the correspondence or signed initial
contract sent by the Failed Institution to request your services and an invoice. In the case of law
firms (or other professional firms) retained by the Failed Institution, enclose an itemized invoice
detailing charges accruing prior to failure. For appraisal services, enclose proof that the appraisal
was completed.
• Other Types of Claims: You must enclose a copy of documents that substantiate the nature and
amount of the claim. While you may enclose a copy of the complaint that you filed with a court, this
alone is not sufficient to establish your claim.
SUBMITTING YOUR CLAIM
There are two ways to submit your claim:
Online:
(r
ecommended)
By Mail:
FDIC NDCWeb: https://www5.fdic.gov/NDCWeb
Electronically file your claim via the internet by completing an online Proof of Claim
form and attaching supporting documentation. Submitting your claim via the FDIC
website is convenient, secure, and inexpensive, and will also help to expedite the
handling of your claim. It is highly recommended.
FDIC as Receiver for Almena State Bank
Attention: Claims Agent
1601 Bryan Street
Dallas, TX 75201
If you choose this option, we recommend you send all documentation by U.S.
certified mail or a commercial service that can provide you with a receipt of delivery.
Please ensure that the Proof of Claim be the top document of your mailing. There is
no need for a cover letter. Please do not send originals.
Vie
w next page to access form FDIC 7200/19e
