Forms Relating to Processing Deposit Insurance Claims

OMB 3064-0143

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.

The latest form for Forms Relating to Processing Deposit Insurance Claims expires 2023-09-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 7200/26 7200/26 Depositor Interview Form and Instruction
Form 7200/24 7200/24 Claimant Verification Form and Instruction
Form 7200/18 7200/18 Declaration for Irrevocable Trust Form and Instruction
Form 7200/15 7200/15 Declaration for Plan and Trust Form and Instruction
Form 7200/14 7200/14 Declaration for Health and Welfare Plan Form and Instruction
Form 7200/13 7200/13 Declaration for Custodian Deposit Form and Instruction
Form 7200/12 7200/12 Declaration for defined Benefit Plan Form and Instruction
Form 7200/11 7200/11 Declaration for IRA/KEOGH Deposit Form and Instruction
Form 7200/10 7200/10 Declaration for Defined Contribution Plan Form and Instruction
Form 7200/09 7200/09 Declaration for Testamentary Deposit (In Trust For or Payable on Death) Form and Instruction
Form 7200/08 7200/08 Declaration for Joint Ownership Report Form and Instruction
Form 7200/07 7200/07 Declaration of Independent Activity for Unincorporated Association Form and Instruction
Form 7200/06 7200/06 Declaration of Independent Activity Form and Instruction
Form 7200/05 7200/05 and 7200/27 - Declaration for Trust Account Form and Instruction
Form 7200/04 7200/04 Declaration for Government Deposit Form and Instruction
SPST 0143 Forms for Processing Deposit Insurance Claims 2023 Renewal FINAL.docx Supporting Statement A
FR2-0143 Forms Relating to Processing Deposit Insurance Claims 88 FR 65678 Sept 25 2023.pdf Supplementary Document
FR1-0143 Forms Relating to Processing Deposit Insurance Claims 88 FR 47503 JUkly 24 2023.pdf Supplementary Document
7200/26 Depositor Interview Form and Instruction
7200/24 Claimant Verification Form and Instruction
7200/18 Declaration for Irrevocable Trust Form and Instruction
7200/15 Declaration for Plan and Trust Form and Instruction
7200/14 Declaration for Health and Welfare Plan Form and Instruction
7200/13 Declaration for Custodian Deposit Form and Instruction
7200/12 Declaration for defined Benefit Plan Form and Instruction
7200/11 Declaration for IRA/KEOGH Deposit Form and Instruction
7200/10 Declaration for Defined Contribution Plan Form and Instruction
7200/09 Declaration for Testamentary Deposit (In Trust For or Payable on Death) Form and Instruction
7200/08 Declaration for Joint Ownership Report Form and Instruction
7200/07 Declaration of Independent Activity for Unincorporated Association Form and Instruction
7200/06 Declaration of Independent Activity Form and Instruction
7200/05 and 7200/27 - Declaration for Trust Account Form and Instruction
7200/04 Declaration for Government Deposit Form and Instruction
Exhibit B, The standard agency agreement, or the non-standard agency agreement
Exhibit A, Affidavit of Agency Account form
Electronic file on customers, "Broker Input File Requirements"
Deposit Broker Submission Checklist

All Historical Document Collections

202307-3064-006 Approved without change	Extension without change of a currently approved collection	2023-09-26
202201-3064-010 Approved without change	No material or nonsubstantive change to a currently approved collection	2022-01-26
202111-3064-009 Approved without change	No material or nonsubstantive change to a currently approved collection	2021-11-19
202005-3064-002 Approved without change	Extension without change of a currently approved collection	2020-08-13
201705-3064-001 Approved without change	Revision of a currently approved collection	2017-05-23
201401-3064-001 Approved with change	Revision of a currently approved collection	2014-01-31
201301-3064-007 Approved without change	Extension without change of a currently approved collection	2013-05-13
200911-3064-003 Approved without change	Revision of a currently approved collection	2010-02-02
200806-3064-001 Approved without change	Extension without change of a currently approved collection	2008-06-19
200505-3064-002 Approved without change	Extension without change of a currently approved collection	2005-05-19
200204-3064-002 Approved without change	Existing collection in use without an OMB Control Number	2002-04-17

OMB Details

7200/04 – Declaration for Government Deposit

Federal Enterprise Architecture: Economic Development - Financial Sector Oversight

Form 7200-04

Declaration for Government Deposit

www.fdic.gov/regulations/laws/forms/claims.html

Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.