Information Collection

7200/14 Declaration for Health and Welfare Plan

IC 243102 under ICR 202005-3064-002 · OMB 3064-0143.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3064-0143 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 7200/14 7200/14 Declaration for Health and Welfare Plan	Form and Instruction
7200/14 Declaration for Health and Welfare Plan 7200-14 FINAL; Expiration 20200831.docx www.fdic.gov/resources/forms/deposit-claims-and-asset-sales/	Form and Instruction

IC Title:

7200/14 Declaration for Health and Welfare Plan

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 12 CFR 330

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	7200/14	Declaration for Health and Welfare Plan	7200-14 FINAL; Expiration 20200831.docx	https://www.fdic.gov/resources/forms/deposit-claims-and-asset-sales/	Yes	Yes	Fillable Printable

Line of Business: Economic Development

Subfunction: Financial Sector Oversight

Privacy Act System of Records

Title: FDIC 30-64-0013

FR Citation: 80 FR 66981

Number of Respondents: 12

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 33 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.