7200/14 Declaration for Health and Welfare Plan

Forms Relating to Processing Deposit Insurance Claims

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3064-0143 can be found here:

Documents and Forms

Document Name Document Type
Form 7200/14 7200/14 Declaration for Health and Welfare Plan Form and Instruction
7200/14 Declaration for Health and Welfare Plan _f7200-14.pdf Form and Instruction
7200/14 Declaration for Health and Welfare Plan _f7200-14.pdf Form and Instruction
Justification Memo 0143 -NS Revisions All Forms New DRO Address.docx Justification Memo Non-Substantive Change to Deposit Insurance Claim Forms IC Document
Justification Memo 0143 -NS Revisions All Forms New DRO Address.docx Justification Memo Non-Substantive Change to Deposit Insurance Claim Forms IC Document

Information Collection (IC) Details

IC Title:	7200/14 Declaration for Health and Welfare Plan	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 12 CFR 330

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	7200/14	Declaration for Health and Welfare Plan	_f7200-14.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Economic Development

Subfunction: Financial Sector Oversight

Privacy Act System of Records
Title: FDIC 30-64-0013	FR Citation: 80 FR 66981

Number of Respondents: 12	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 33 %

	Approved	Previously Approved
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Justification Memo Non-Substantive Change to Deposit Insurance Claim Forms	Justification Memo 0143 -NS Revisions All Forms New DRO Address.docx	11/19/2021

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