Information Collection

Certified Statement for Deposit Insurance Assessment

IC 31803 under ICR 202311-3064-006 · OMB 3064-0057.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 6420-07 Certified Statement for Deposit Insurance Assessment	Form and Instruction
6420-07 Quarterly Certified Statement Invoice 6420-07.pdf	Form and Instruction
6420-07 Quarterly Certified Statement Invoice 6420-07.pdf	Form and Instruction
Justification Memo Non Substantive Revisions 3064-0057 Novemebr 2023.docx Justification Memo for Non-Substantive Change 3064-0057	IC Document
Justification Memo Non Substantive Revisions 3064-0057 Novemebr 2023.docx Justification Memo for Non-Substantive Change 3064-0057	IC Document

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 327

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	6420-07	Quarterly Certified Statement Invoice	6420-07.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Economic Development

Subfunction: Financial Sector Oversight

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,755

Number of Respondents for Small Entity: 3,475

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	19,020	19,020
Annual IC Time Burden (Hours)	6,340	6,340
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Justification Memo for Non-Substantive Change 3064-0057	Justification Memo Non Substantive Revisions 3064-0057 Novemebr 2023.docx	11/30/2023

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