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Holocaust Insurance Claims

Generic Fee Waiver Forms for Financial Institutions

Effective August 11, 2005, ________________________________________________, a financial institution operating in Florida, agrees to voluntarily waive the wire-transfer or processing fees to our customers for wire-transfer payments for Holocaust-related reparations or restitution. Upon receipt of a written request and reasonable documentation from our customers, we will waive all of our fees associated with processing these wire-transfer payments.

Name of Institution (please print)________________________________________________

Signatory (please print):_______________________________________________________

Title (please print):___________________________________________________________

Signature:__________________________________________________________________

Contact Telephone Number:___________________________________________________

Information to be posted on Website (please print)

Name of Financial Institution:

__________________________________________________________________________

Address for Sending Written Requests:

__________________________________________________________________________

City____________________________ State________________ Zip___________________

Contact Telephone Number for Questions (preferably toll-free):_______________________

Send this form to:

Lynn Grossman
Florida Department of Financial Services
200 E. Gaines Street
Room 624G
Tallahassee, Fl 32399-4205
850-413-4160