Information Collection

7200/14 Declaration for Health and Welfare Plan

IC 243102 under ICR 202307-3064-006 · OMB 3064-0143.

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 f7200-14.pdf	Form and Instruction
7200/14 Declaration for Health and Welfare Plan f7200-14.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	f7200-14.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Economic Development

Subfunction: Financial Sector Oversight

Privacy Act System of Records

Title: FDIC 30-64-0013

FR Citation: 87 FR 66178

Number of Respondents: 1

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1	-11	12
Annual IC Time Burden (Hours)	1	-11	12
Annual IC Cost Burden (Dollars)	0	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.