Business Assistance Form

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⚠️ Notice: This information collection may be referencing outdated material.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 6422/11 Business Assistance Form Form and Instruction
6422/11 Business Assistance Form Business Assistance Form (1).docx ask.fdic.gov/FDICBusinessAssistanceForm Form and Instruction
6422/11 Business Assistance Form Business Assistance Form (1).docx ask.fdic.gov/FDICBusinessAssistanceForm Form and Instruction
6422/11 Business Assistance Form (Spanish) Business Assistance Sp (1).docx ask.fdic.gov/FDICBusinessAssistanceForm?lang=esp_ES Form and Instruction
6422/11 Business Assistance Form (Spanish) Business Assistance Sp (1).docx ask.fdic.gov/FDICBusinessAssistanceForm?lang=esp_ES Form and Instruction

Information Collection (IC) Details

IC Title:	Business Assistance Form	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	6422/11	Business Assistance Form	Business Assistance Form (1).docx	https://ask.fdic.gov/FDICBusinessAssistanceForm	Yes	Yes	Fillable Fileable
Form and Instruction	6422/11	Business Assistance Form (Spanish)	Business Assistance Sp (1).docx	https://ask.fdic.gov/FDICBusinessAssistanceForm?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: 225	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	225	25	200
Annual IC Time Burden (Hours)	56	6	50
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.