Forms Relating to Processing Deposit Insurance Claims

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 7200-04 Declaration for Government Deposit	Form and Instruction	Modified	Available
Form 7200/26 Depositor Interview Form	Form and Instruction	New	Available
Form 7200/24 Claimant Verification	Form and Instruction	New	Available
Form 7200/14 Declaration or Health and Welfare Plan	Form and Instruction	New	Available
Form 7200/09 Declaration for Testamentary Deposit	Form and Instruction	New	Available
Form 7200/05 Declaration for Revocable Trust	Form and Instruction	New	Available
7200-18.doc	Supplementary Document	Uploaded 2017-05-23	Available
7200-15.doc	Supplementary Document	Uploaded 2017-05-23	Available
7200-13.doc	Supplementary Document	Uploaded 2017-05-23	Available
7200-12.docx	Supplementary Document	Uploaded 2017-05-23	Available
7200-11.doc	Supplementary Document	Uploaded 2017-05-23	Available
7200-10.pdf	Supplementary Document	Uploaded 2017-05-23	Available
7200-08.doc	Supplementary Document	Uploaded 2017-05-23	Available
7200-07.doc	Supplementary Document	Uploaded 2017-05-23	Available
7200-06.doc	Supplementary Document	Uploaded 2017-05-23	Available
FR2 - 82 FR 23569 (May 23 2017).pdf	Supplementary Document	Uploaded 2017-05-23	Available
FR1 - 82 FR 10004 (Feb 9 2017).pdf	Supplementary Document	Uploaded 2017-05-23	Available
SPST-0143 Forms for Processing Deposit Insurance Claims - 2017.docx	Supporting Statement A	Uploaded 2017-05-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
31961	7200/04 – Declaration for Government Deposit	Form and Instruction	Modified	Declaration for Government Deposit
226666	Exhibit B, the standard agency agreement, or the non-standard agency agreement		New
226665	Diskette, following "Broker Input File Requirements"		New
226664	Diskette, following "Broker Input File Requirements"		New
226663	Deposit Broker Submission Checklist		New
226662	7200/26 – Depositor Interview Form	Form and Instruction	New	Depositor Interview Form
226661	7200/24 – Claimant Verification	Form and Instruction	New	Claimant Verification
226658	7200/14 – Declaration or Health and Welfare Plan	Form and Instruction	New	Declaration or Health and Welfare Plan
226653	7200/09 – Declaration for Testamentary Deposit	Form and Instruction	New	Declaration for Testamentary Deposit
226649	7200/05 – Declaration for Revocable Trust	Form and Instruction	New	Declaration for Revocable Trust

ICR Details

OMB Control No: 3064-0143	ICR Reference No: 201705-3064-001
Status: Historical Active	Previous ICR Reference No: 201401-3064-001
Agency/Subagency: FDIC	Agency Tracking No: 3064-0143
Title: Forms Relating to Processing Deposit Insurance Claims
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/10/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/23/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2020	36 Months From Approved	08/31/2017
Responses	1,036	0	1,311
Time Burden (Hours)	581	0	707
Cost Burden (Dollars)	0	0	0

---

Abstract: Depositors and deposit brokers with funds in failed institutions may be required to provide information about different "ownerships rights and capacities" and the amount of funds held in the institution. This information assists the FDIC in making determinations regarding deposit insurance coverage. The collection involves forms used by the FDIC to obtain information from depositors and deposit brokers necessary to supplement the records of failed insured depository institutions to make determinations regarding deposit insurance coverage. The information provided enables the FDIC to identify the actual owners of an account, each owner’s interest in the account, and the right and capacity in which the deposit is insured.

---

Authorizing Statute(s): US Code: 12 USC 1821(a) and (f) Name of Law: Federal Deposit Insurance Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 10004	02/09/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 23569	05/23/2017
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
7200/04 – Declaration for Government Deposit	7200-04	Declaration for Government Deposit
7200/05 – Declaration for Revocable Trust	7200/05	Declaration for Revocable Trust
7200/09 – Declaration for Testamentary Deposit	7200/09	Declaration for Testamentary Deposit
7200/14 – Declaration or Health and Welfare Plan	7200/14	Declaration or Health and Welfare Plan
7200/24 – Claimant Verification	7200/24	Claimant Verification
7200/26 – Depositor Interview Form	7200/26	Depositor Interview Form
Deposit Broker Submission Checklist
Diskette, following "Broker Input File Requirements"
Diskette, following "Broker Input File Requirements"
Exhibit B, the standard agency agreement, or the non-standard agency agreement

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,036	1,311	0	0	-275	0
Annual Time Burden (Hours)	581	707	0	0	-126	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/23/2017

---