Forms Relating to Processing Deposit Insurance Claims

Forms and Documents

Document Name	Status
Form 7200/26 7200/26 Depositor Interview Form and Instruction	Modified
Form 7200/24 7200/24 Claimant Verification Form and Instruction	Modified
Form 7200/18 7200/18 Declaration for Irrevocable Trust Form and Instruction	Modified
Form 7200/15 7200/15 Declaration for Plan and Trust Form and Instruction	Modified
Form 7200/14 7200/14 Declaration for Health and Welfare Plan Form and Instruction	Modified
Form 7200/13 7200/13 Declaration for Custodian Deposit Form and Instruction	Modified
Form 7200/12 7200/12 Declaration for defined Benefit Plan Form and Instruction	Modified
Form 7200/11 7200/11 Declaration for IRA/KEOGH Deposit Form and Instruction	Modified
Form 7200/10 7200/10 Declaration for Defined Contribution Plan Form and Instruction	Modified
Form 7200/09 7200/09 Declaration for Testamentary Deposit (In Trust For or Payable on Death) Form and Instruction	Modified
Form 7200/08 7200/08 Declaration for Joint Ownership Report Form and Instruction	Modified
Form 7200/07 7200/07 Declaration of Independent Activity for Unincorporated Association Form and Instruction	Modified
Form 7200/06 7200/06 Declaration of Independent Activity Form and Instruction	Modified
Form 7200/05 7200/05 Declaration for Trust Form and Instruction	Modified
Form 7200/04 7200/04 Declaration for Government Deposit Form and Instruction	Modified
Justification Memo 0143 -NS Revisions All Forms New DRO Address January 2022.docx Justification for No Material/Nonsubstantive Change	2022-01-26
SPST 0143 Forms for Processing Deposit Insurance Claims 2020 FINAL.docx Supporting Statement A	2020-08-13
FR2 0143 Forms for Processing Deposit Insurance Claims 85 FR 47967 August 7 2020.pdf Supplementary Document	2020-08-07
FR1 0143 Forms Related to Processing Deposit Insurance Claims 85 FR 33667 June 2 2020.pdf Supplementary Document	2020-08-03

IC Document Collections

IC ID	Document Title	Status
243112	7200/26 Depositor Interview Form and Instruction	Modified
243110	7200/24 Claimant Verification Form and Instruction	Modified
243106	7200/18 Declaration for Irrevocable Trust Form and Instruction	Modified
243103	7200/15 Declaration for Plan and Trust Form and Instruction	Modified
243102	7200/14 Declaration for Health and Welfare Plan Form and Instruction	Modified
243101	7200/13 Declaration for Custodian Deposit Form and Instruction	Modified
243100	7200/12 Declaration for defined Benefit Plan Form and Instruction	Modified
243099	7200/11 Declaration for IRA/KEOGH Deposit Form and Instruction	Modified
243096	7200/10 Declaration for Defined Contribution Plan Form and Instruction	Modified
243095	7200/09 Declaration for Testamentary Deposit (In Trust For or Payable on Death) Form and Instruction	Modified
243093	7200/08 Declaration for Joint Ownership Report Form and Instruction	Modified
243092	7200/07 Declaration of Independent Activity for Unincorporated Association Form and Instruction	Modified
243091	7200/06 Declaration of Independent Activity Form and Instruction	Modified
243090	7200/05 Declaration for Trust Form and Instruction	Modified
243089	7200/04 Declaration for Government Deposit Form and Instruction	Modified
226666	Exhibit B, the standard agency agreement, or the non-standard agency agreement	Unchanged
226665	Diskette, following "Broker Input File Requirements"	Unchanged
226664	Diskette, following "Broker Input File Requirements"	Unchanged
226663	Deposit Broker Submission Checklist	Unchanged

ICR Details

OMB Control No: 3064-0143	ICR Reference No: 202201-3064-010
Status: Received in OIRA	Previous ICR Reference No: 202111-3064-009
Agency/Subagency: FDIC	Agency Tracking No:
Title: Forms Relating to Processing Deposit Insurance Claims
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 01/26/2022

	Requested	Previously Approved
Expiration Date	09/30/2023	09/30/2023
Responses	1,045	1,045
Time Burden (Hours)	590	590
Cost Burden (Dollars)	0	0

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Abstract: Depositors and deposit brokers with funds in failed institutions may be required to provide information about different "ownerships rights and capacities" and the amount of funds held in the institution. This information assists the FDIC in making determinations regarding deposit insurance coverage. The collection involves forms used by the FDIC to obtain information from depositors and deposit brokers necessary to supplement the records of failed insured depository institutions to make determinations regarding deposit insurance coverage. The information provided enables the FDIC to identify the actual owners of an account, each owner’s interest in the account, and the right and capacity in which the deposit is insured.

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Authorizing Statute(s): US Code: 12 USC 1821(a) and (f) 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:
	85 FR 33667	06/02/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 47967	08/07/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 19

IC Title	Form No.	Form Name
7200/04 Declaration for Government Deposit	7200/04	Declaration for Government Deposit
7200/05 Declaration for Trust	7200/05	Declaration for Trust
7200/06 Declaration of Independent Activity	7200/06	Declaration of Independent Activity
7200/07 Declaration of Independent Activity for Unincorporated Association	7200/07	Declaration of Independent Activity for Unincorporated Association
7200/08 Declaration for Joint Ownership Report	7200/08	Declaration for Joint Ownership Deposit
7200/09 Declaration for Testamentary Deposit (In Trust For or Payable on Death)	7200/09	Declaration for Testamentary Deposit (In Trust For or Payable on Death)
7200/10 Declaration for Defined Contribution Plan	7200/10	Declaration for Defined Contribution Plan
7200/11 Declaration for IRA/KEOGH Deposit	7200/11	Declaration for IRA/KEOGH Deposit
7200/12 Declaration for defined Benefit Plan	7200/12	Declaration for Defined Benefit Plan
7200/13 Declaration for Custodian Deposit	7200/13	Declaration for Custodian Deposit
7200/14 Declaration for Health and Welfare Plan	7200/14	Declaration for Health and Welfare Plan
7200/15 Declaration for Plan and Trust	7200/15	Declaration for Plan and Trust
7200/18 Declaration for Irrevocable Trust	7200/18	Declaration for Irrevocable Trust
7200/24 Claimant Verification	7200/24	Claimant Verification
7200/26 Depositor Interview	7200/26	Depositor Interview
Deposit Broker Submission Checklist
Diskette, following "Broker Input File Requirements"
Diskette, following "Broker Input File Requirements"
Exhibit B, the standard agency agreement, or the non-standard agency agreement

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ICR Summary 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	1,045	1,045	0	0	0	0
Annual Time Burden (Hours)	590	590	0	0	0	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.     Yes

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.     Yes

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: 01/26/2022

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