Customer Assistance Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 6422/04 Customer Assistance	Form and Instruction	Modified	Available
Form 6422/15 Deposit Insurance Inquiry	Form and Instruction	Modified	Available
Form 6422/11 Business Assistance Form	Form and Instruction	Modified	Available
FR2 - 83 FR 40288 (Aug 14 2018).pdf	Supplementary Document	Uploaded 2018-09-27	Available
FR1 - 83 FR 24116 (May 24 2018).pdf	Supplementary Document	Uploaded 2018-09-27	Available
SPST-0134 2018 - 8-3-18.doc	Supporting Statement A	Uploaded 2018-09-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
31943	Customer Assistance	Form and Instruction	Modified
227590	Deposit Insurance Inquiry	Form and Instruction	Modified
202928	Business Assistance Form	Form and Instruction	Modified

ICR Details

OMB Control No: 3064-0134	ICR Reference No: 201809-3064-005
Status: Active	Previous ICR Reference No: 201707-3064-002
Agency/Subagency: FDIC	Agency Tracking No: 3064-0134
Title: Customer Assistance Forms
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/27/2018
	Date Received in OIRA: 09/28/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2021	36 Months From Approved	11/30/2018
Responses	8,200	0	15,000
Time Burden (Hours)	2,050	0	3,751
Cost Burden (Dollars)	0	0	0

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Abstract: This collection facilitates the collection of information from customers of financial institutions that have inquiries or complaints about service. Customers or businesses may document their complaints or inquiries to the FDIC using a letter or optional forms (Form 6422/04; Form 6422/11; Form 6422/15). The Forms are used to facilitate online completion and submission of the complaints or inquiries and to shorten FDIC response times by making it easier to identify the nature of the complaint and to route the customer or business inquiry to the appropriate FDIC contact.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 24116	05/24/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 40288	08/14/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Deposit Insurance Inquiry	6422/15, 6422/15	Deposit Insurance Form ,   Deposit Insurance Form (Spanish)
Customer Assistance	6422/04, 6422/04	Customer Assistance Form ,   Customer Assistance Form (Spanish)
Business Assistance Form	6422/11, 6422/11	Business Assistance Form ,   Business Assistance Form (Spanish)

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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	8,200	15,000	0	0	-6,800	0
Annual Time Burden (Hours)	2,050	3,751	0	0	-1,701	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:

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Annual Cost to Federal Government: $0

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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

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Common Form ICR:  No

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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: 09/28/2018

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