Customer Assistance

Customer Assistance Forms

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3064-0134 can be found here:

Documents and Forms

Document Name Document Type
Form 6422/04 Customer Assistance Form and Instruction
6422/04 Customer Assistance Form Customer Assistance Form (1).docx ask.fdic.gov/FDICCustomerAssistanceForm/ Form and Instruction
6422/04 Customer Assistance Form (Spanish) Customer Assistance Sp (1).docx ask.fdic.gov/FDICCustomerAssistanceForm/FDICCustomerAssistanceForm?lang=esp_ES Form and Instruction

Information Collection (IC) Details

IC Title:	Customer Assistance	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	6422/04	Customer Assistance Form	Customer Assistance Form (1).docx	https://ask.fdic.gov/FDICCustomerAssistanceForm/	Yes	Yes	Fillable Fileable
Form and Instruction	6422/04	Customer Assistance Form (Spanish)	Customer Assistance Sp (1).docx	https://ask.fdic.gov/FDICCustomerAssistanceForm/FDICCustomerAssistanceForm?lang=esp_ES	Yes	Yes	Fillable Fileable

Line of Business: Economic Development

Subfunction: Financial Sector Oversight

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	7,000	-5,750	12,750
Annual IC Time Burden (Hours)	1,750	-1,438	3,188
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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