1 Credit Union Name: 
2 Address:  , ,  
3 NCUA Charter Number: 
4 Assessment Date: 
5 Total Shares and Deposits: 
6 Excess Shares and Deposits: 
7 Previous Excess Shares High: 
8 Increase in Shares and Deposits: 
9 Assessment Amount (Item 8 x 1.25%): 
10 NCUA 5300 Agree: 
11 NCUA Memo: 
12 Risk Standard Compliance: 
13 Risk Standard Memo: 
14 I hereby certify that this report is true and correct to the best of my knowledge and belief: 
15 Submitted by: 
16 Title\Position: 
17 Email Address: 
18 Date Submitted: 

Massachusetts Credit Union Share Insurance Corp.

233 Needham Street, Suite 510

Newton, Mass. 02464

(800) 622-4015 (617) 758-0544

(617) 244-3028 fax info@msic.org

 MSIC Logo

1 Credit Union Name: 
2 Address:  , ,  
3 NCUA Charter Number: 
4 Assessment Date: 
5 Total Shares and Deposits: 
6 Excess Shares and Deposits: 
7 Previous Excess Shares High: 
8 Increase in Shares and Deposits: 
9 Assessment Amount (Item 8 x 1.25%): 
10 NCUA 5300 Agree: 
11 NCUA Memo: 
12 Risk Standard Compliance: 
13 Risk Standard Memo: 
14 I hereby certify that this report is true and correct to the best of my knowledge and belief: 
15 Submitted by: 
16 Title\Position: 
17 Email Address: 
18 Date Submitted: