Form FDIC Form 6422/11 FDIC Form 6422/11 Business Assistance Form

PRIVACY ACT STATEMENT

Form FDIC 6422/11

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 third parties as authorized by law or used according to any of the other routine uses described in the FDIC Consumer Complaint and Inquiry Records System of Records (FDIC-30-64-0005).  A complete copy of this System of Records is available at

http://www.fdic.gov/regulations/laws/rules/2000-4000.html#fdic200030--64--0005.   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.

PAPERWORK REDUCTION ACT NOTICE

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.

MAILING ADDRESS

FDIC Consumer Response Center
1100 Walnut Street, Box #11
Kansas City, MO 64106
1-877-ASK-FDIC (1-877-275-3342)
(Monday - Friday 8:00 am to 8:00 pm EST)
703-812-1020 (Fax number)

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OMB NUMBER: 3064-0134

EXPIRATION DATE: 8/31/2015

Federal Deposit Insurance Corporation BUSINESS ASSISTANCE FORM
INSTRUCTIONS: Please print or type. Complete this form if you represent a business and have an inquiring or concern about a financial institution. Please note that if you have a complaint, the FDIC cannot (1) act as a court of law or as a lawyer on your behalf (2) cannot give you legal or financial advice, or (3) cannot become actively involved in complaints that are in litigation or have been litigated.
SECTION I - REQUESTOR INFORMATION
NAME OF BUSINESS CONTACT/BUSINESS NAME			SALUTATION (Check one)
     			Mr. Ms. Mrs. Doctor Honorable
STREET ADDRESS		CONTACT PHONE NUMBER			ALTERNATE PHONE NUMBER
     
CITY	STATE		ZIP CODE			COUNTRY
     	     		     			     
EMAIL ADDRESS
     
PLEASE ANSWER THE FOLLOWING THREE QUESTIONS:
1. WHAT IS THE BEST WAY TO CONTACT YOU? (Check one) Phone Mail Email
2. WHAT IS THE BEST TIME TO CONTACT YOU? (Check one) Morning Afternoon Evening
3. IS THIS REQUEST SUBMITTED BY A THIRD PARTY ON BEHALF OF YOUR BUSINESS? YES NO (If “Yes,” provide the name and contact information for the business representative below.) If the address is the same, check this box .
NAME (Last, First, MI)
     
STREET ADDRESS		CONTACT PHONE NUMBER			ALTERNATE PHONE NUMBER
     
CITY	STATE		ZIP CODE				COUNTRY
     	     		     				     
EMAIL ADDRESS
     
SECTION II – 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? YES NO (If “YES,” provide representative’s information below. If you list someone, you authorize FDIC to communicate with the individual and provide information to that individual.)
NAME OF REPRESENTATIVE (Last, First, MI)			RELATIONSHIP
     			     
STREET ADDRESS		CONTACT PHONE NUMBER			ALTERNATE PHONE NUMBER
     		     			     
CITY	STATE		ZIP CODE				COUNTRY
     	     		     				     
EMAIL ADDRESS
     
SECTION III - FINANCIAL INSTITUTION INFORMATION
DOES YOUR REQUEST INVOLVE A SPECIFIC FINANCIAL INSTITUTION? YES NO (If YES, provide the following information.)
NAME OF FINANCIAL INSTITUTION
STREET ADDRESS				INSTITUTION PHONE NUMBER
     				     
CITY	STATE		ZIP CODE				COUNTRY
     	     		     				     

SECTION III - FINANCIAL INSTITUTION INFORMATION (Cont’d)
Indicate the type of account (Check all that apply.) Credit Card Checking Mortgage Other      
SECTION IV – COMPLAINT INFORMATION (Describe your inquiry or concern, including any names, phone numbers, and a full description of the issue with the amount(s) and date(s) of any transaction(s). Do not include personal or confidential information such as your social security, credit card, or bank account numbers. If you need to provide COPIES of any supporting documentation such as contracts, monthly statements, receipts or any correspondence with the bank (do not send original documents), you may mail or fax this information to the address above.) NOTE: 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. Checking this box authorizes the FDIC to respond and investigate (if applicable) your concerns.
1. Have you tried to resolve your INQUIRY OR CONCERN with your financial institution or company? YES NO (If Yes, on what date did you attempt to resolve the complaint?)      
2. how DID you trY to resolve your complaint (Check all that apply and provide contact information.) Telephone Mail In person Other (Specify)      .
Name of Contact	Position Title
     	     
3. Have you filed a INQUIRY OR CONCERN contacted another government agency? YES NO (If YES, provide the name of the agency in the space provided below.)
NAME OF AGENCY
     
DESCRIPTION (Describe below the nature of your complaint, inquiry, or concern.)
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SECTION V – COMPLAINT INFORMATION ( Cont’d)

DESIRED RESOLUTION (What action by the financial institution or company would resolve this matter to your satisfaction?)

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