Certification of Compliance with Mandatory Bars to Employment

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3064-0121 can be found here:

Documents and Forms

Document Name Document Type
Form FDIC-2120/16 Certification of Compliance with Mandatory Bars to Employment Form
FDIC-2120/16 Applicant Certification Statement Form 2120-16 Applicant Certification.pdf Form
FDIC-2120/16 Applicant Certification Statement Form 2120-16 Applicant Certification.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Certification of Compliance with Mandatory Bars to Employment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 12 CFR Part 336, Subpart B (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	FDIC-2120/16	Applicant Certification Statement	Form 2120-16 Applicant Certification.pdf		Yes	Yes	Fillable Printable

Line of Business: Economic Development

Subfunction: Financial Sector Oversight

Privacy Act System of Records
Title: 30-64-0015 Personnel Records	FR Citation: 80 FR 66982

Number of Respondents: 528	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	528	28	500
Annual IC Time Burden (Hours)	88	5	83
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.