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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

Collection of this information is authorized by 12 U.S.C. §§ 1818 and 1819 and 15 U.S.C. § 57a(f). The information you provide to the FDIC on this form will be used to investigate and respond to your complaint or inquiry. The information you provide may be disclosed to the institution which is the subject of the complaint or inquiry and to any third party sources, when necessary to investigate or resolve the complaint or inquiry; to the Federal or State supervisory authority that has direct supervision over the financial institution that is the subject of the complaint or inquiry; to appropriate Federal, state or local authorities agencies if a violation or possible violation of a civil or criminal law is apparent; to a congressional office in response to an inquiry made at your request; to a court, magistrate or administrative tribunal in the event of litigation, or in accordance with the other "routine uses of records" listed in the FDIC's Consumer Complaint and Inquiry System of Records, # 30-64-0005. Completing this form is voluntary, but failure to provide all of the information may delay or preclude investigation of your complaint or inquiry.

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
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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