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Federal Deposit
Insurance Corporation

Each depositor insured to at least $250,000 per insured bank

FDIC Business Assistance Form

Formulario de asistencia para negocios
(En Español)
   FDIC 3064-0134  Expiration Date: 09/30/2018

Privacy Act Statement

The collection of this information is authorized by Section 9 of the Federal Deposit Insurance Act (12 U.S.C. §1819) and Section 202(f) of Title II of the Federal Trade Improvement Act (15 U.S.C. §57a(f)). The FDIC will use this information to respond to your questions and requests for assistance involving activities or practices of FDIC-insured depository institutions. Submitting this information to the FDIC is voluntary. Failure to submit all of the information requested and to complete the form entirely could delay or prevent the response to your request. The information provided by individuals is protected by the Privacy Act, 5 USC §552a. The information may be furnished to the institution which is the subject of the complaint or inquiry; to the Federal or State supervisory authority that has direct supervision over the financial institution; to appropriate Federal, state, local or foreign law enforcement authorities; to a court, administrative tribunal, or a party in litigation; to contractors, agents and other third parties as authorized by law, and in accordance with any of the other routine uses described in the FDIC Consumer Complaint and Inquiry Records (FDIC-30-64-0005) System of Records. A complete copy of this System of Records is available at www.fdic.gov/about/privacy. If you have questions or concerns about the collection or use of the information, you may contact the FDIC’s Chief Privacy Officer at Privacy@fdic.gov.

Last Updated 09/23/2015

Paperwork Reduction Act Statement

Public reporting burden for this collection of information is estimated to average .25 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and review the collection of information.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17th Street, N.W., Washington, D.C. 20429, and the Office of Management and Budget, Paperwork Reduction Project (3064-0134), Washington, D.C. 20503.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection unless it displays a currently valid OMB control number.

Last Updated 09/23/2015

Please complete this form if you represent a business and have an inquiry or concern about a financial institution. Once the form has been submitted, you will receive a Confirmation Page indicating that your request has been received.

Please note:
  • We cannot act as a court of law or as a lawyer on your behalf.
  • We cannot give you legal or financial advice.
  • We cannot become actively involved in complaints that are in litigation or have been litigated.
* Required Fields
Indicate whether you are a:
Requester Information:
 
Name of Business Contact
Business Name
Salutation
Title
Middle Name
Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
Home Phone
Business Phone
*Mailing City *Mailing State/Province  
*Mailing Zip/Postal Code Zip Ext  
*Mailing Country
  Best Way to Contact
  Best Time to Contact
 
Is this request submitted by a third party on behalf of the business?  Yes   No
Name and Contact Information for Business Representative
Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
Home Phone
Business Phone
    Same address as above?    No   Yes
*Mailing City *Mailing State/Province  
*Mailing Zip/Postal Code Zip Ext  
*Mailing Country
 
 
Additional Contact Information:
 
Do you want us to communicate with another individual on your behalf, such as an advisor, attorney, or other person representing you?
If you list someone below, you authorize us to communicate with the individual and provide information to that individual.
 
Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
Home Phone
Business Phone
*Mailing City *Mailing State/Province  
*Mailing Zip/Postal Code Zip Ext  
*Mailing Country
 
Does your request involve a specific financial institution?
Financial Institution Lookup (New Window)
Mailing City Mailing State/Province  
Mailing Zip/Postal Code Zip Ext  
Mailing Country
Institution Phone Number Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
FI: Type of accounts
Have you tried to resolve your inquiry or concern with your financial institution or company?
MM/DD/YYYY   *Resolve: How    Phone   Mail   In Person   Other 
Resolve: Contact Name Resolve:Title
Have you filed a complaint or contacted another government agency?
*Gov Agency: Agency Name
 
 
*Please describe below the nature of your inquiry or concern.
Please be advised that the FDIC may contact your financial institution or company to obtain additional information needed to respond to your inquiry or concern.
 
*Desired Resolution
What action by the financial institution or company would resolve this matter to your satisfaction?
 
 
*Checking this box authorizes the FDIC to respond to your inquiry
 
 

FDIC 6422/11 (06-12)
Last Updated 12/11/2017

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