Certified Statement for Deposit Insurance Assessment

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 6420-07 Quarterly Certified Statement Invoice	Form and Instruction	Modified	Available
FR2 - Certified Statement of Semiannual DI Assessment - 91 FR 50835 ( August 4 2026).pdf	Supplementary Document	Uploaded 2026-08-25	Available
FR1 - Certified Statement of Semiannual DI Assessment - 91 FR 33724 (June 4 2026).pdf	Supplementary Document	Uploaded 2026-08-25	Available
SPST 0057 Certified Statement of Semiannual Deposit Insurance Assessment 2026 Extension FINAL docx.docx	Supporting Statement A	Uploaded 2026-08-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
31803	Certified Statement for Deposit Insurance Assessment	Form and Instruction	Modified	Quarterly Certified Statement Invoice

ICR Details

OMB Control No: 3064-0057	ICR Reference No: 202608-3064-002
Status: Received in OIRA	Previous ICR Reference No: 202311-3064-006
Agency/Subagency: FDIC	Agency Tracking No:
Title: Certified Statement for Deposit Insurance Assessment
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/16/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	09/30/2026
Responses	17,380	19,020
Time Burden (Hours)	5,793	6,340
Cost Burden (Dollars)	0	0

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Abstract: The FDIC collects the quarterly deposit insurance payments by means of direct debits through the Automated Clearing House network. This information collection consists of statements supported by worksheets and reviewed by officials of the insured institutions to confirm that the assessment data is accurate.

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Authorizing Statute(s): US Code: 12 USC 1817(b) and (c) Name of Law: Federal Deposit Insurance Act
  

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:
	91 FR 33724	06/04/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 50835	08/06/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Certified Statement for Deposit Insurance Assessment	6420-07	Quarterly Certified Statement Invoice

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ICR Summary of Burden

table that charts list of burden

	Total Request	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	17,380	19,020	0	0	-1,640	0
Annual Time Burden (Hours)	5,793	6,340	0	0	-547	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? No

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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: 09/16/2026

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