Customer Assistance Forms

OMB 3064-0134

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.

The latest form for Customer Assistance Forms expires 2021-11-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 6422/04 Customer Assistance Form and Instruction
Form 6422/15 Deposit Insurance Inquiry Form and Instruction
Form 6422/11 Business Assistance Form Form and Instruction
FR2-0134 Customer Assistance Forms 86 FR 67707 Nov 22 2021.pdf Supplementary Document
FR1-0134 Consumer Assistance Forms 86 FR 52680 Sept 22 2021.pdf Supplementary Document
3064-0028 SPST FINAL (2021) (WP).docx Supporting Statement A
Customer Assistance Form and Instruction
Deposit Insurance Inquiry Form and Instruction
Business Assistance Form Form and Instruction

All Historical Document Collections

202109-3064-007 Approved without change	Extension without change of a currently approved collection	2021-11-29
201809-3064-005 Approved without change	Extension without change of a currently approved collection	2018-09-28
201707-3064-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2017-07-19
201506-3064-002 Approved without change	Extension without change of a currently approved collection	2015-06-25
201206-3064-007 Approved without change	Revision of a currently approved collection	2012-07-02
200904-3064-001 Approved without change	Revision of a currently approved collection	2009-04-17
200602-3064-004 Approved without change	Extension without change of a currently approved collection	2006-02-23
200301-3064-001 Approved without change	Extension without change of a currently approved collection	2003-01-16
199911-3064-001 Approved without change	New collection (Request for a new OMB Control Number)	1999-11-04

OMB Details

Customer Assistance

Federal Enterprise Architecture: Economic Development - Financial Sector Oversight

Form 6422/04	Customer Assistance Form	ask.fdic.gov/FDICCustomerAssistanceForm/	Form and instruction
Form 6422/04	Customer Assistance Form (Spanish)	ask.fdic.gov/FDICCustomerAssistanceForm/FDICCustomerAssistanceForm?lang=esp_ES	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.